West Palm Beach Florida car accident CONSENT TO RELEASE FORM 1-800-74-TRIAL

The Privacy Act of 1974 (Public Law 93-579) prohibits the government from revealing information from personal files without the express written permission of the person involved. Disclosure of personal records to an West Palm Beach Florida car accident attorney or other representative who is acting on behalf of another person is prohibited, unless the individual to whom the records pertains has consented.
I, ____________________, hereby authorize the Centers for Medicare & Medicaid Services (CMS), its agents and/or contractors to disclose, discuss, and/or release, orally or in writing, information related to my worker’s compensation injury and/or settlement to the individual(s) and/or firm(s) listed below. This consent is for my current ___________ (list nature of claim) claim and is on an ongoing basis. An additional consent to release form will not be necessary unless or until I revoke this authorization (which must be in writing).

CLAIMANT’S WEST PALM BEACH FLORIDA CAR ACCIDENT ATTORNEY: Name and/or Firm

DEFENDANT’S WEST PALM BEACH FLORIDA CAR ACCIDENT ATTORNEY: Name and/or Firm

WORKER’S COMPENSATION/INSURANCE CARRIER:

OTHER:

CLAIMANT’S SIGNATURE DATE SIGNED:

DATE OF INJURY: ____________________
SOCIAL SECURITY #: ____________________
Or HEALTH INSURANCE CLAIM #: ____________________