Law Office Attestation – Authorized Representative Requests

For AUTHORIZED REPRESENTATIVES requesting release of records to representing attorney:
Patient Name:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Authorized Representative (Non-Patient Requestor):

Other
Name of Requestor (Authorized Representative):
Signature of Requestor:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Law Office Attestation:
For any request that is not signed by the patient, records will not be released until appropriate legal documentation such as a Court Order, written authorization, Healthcare Power of Attorney, or other valid legal authority is provided, or until this attestation is completed by the requesting law office.

By signing below, the law office affirms that it has verified the requester’s legal authority, which may include a parent of a minor child, spouse, next of kin, legal guardian, executor or administrator of the patient’s estate, Healthcare Power of Attorney, or Attorney in Fact.
Representing Attorney - Printed Name:
Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty: