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Pennsylvania Trial Lawyers Association
Authorization
EVANS, PORTNOY
& QUINN
301 Grant Street, 36th Floor - One Oxford Centre
Pittsburgh, PA 15219-6401
(412) 765-3800 Telephone
(412) 765-3747 Facsimile
[email protected]
TO: _______________________________
_______________________________
_______________________________
RE:
Date of Birth:
_______________
Date of Accident: _______________
Social
Security #: _______________
Dates of Treatment: _____________
______________________________
This authorization permits the above-referenced provider to send to my attorneys, Evans, Portnoy & Quinn my medical information, records, reports, radiology films and itemized billing statements pertaining to the above-dates of treatment.
The purpose of this request is for use in civil litigation.
PLEASE DO NOT DISCLOSE ANY INFORMATION CONCERNING MY TREATMENT TO ANYONE BUT THE ABOVE ATTORNEYS WITHOUT MY SIGNED AUTHORIZATION.
� This Authorization will remain in effect for a period of one (1) year from the date of my signature.
� I have the right to revoke this Authorization form at any time by providing written notice of my intent to revoke said Authorization.
� A photocopy or facsimile of this Authorization will be considered as valid as the original.
WITNESS:
____________________________ ____________________________________
DATE:______________________________