West Palm Beach Florida car accident information request - Authorization to Obtain Governmental Agency Records and Records

Date:

The undersigned hereby authorizes and requests (insert name of entity) upon the presentation of this authorization to release to the West Palm Beach Florida car accident Law Firm of (name of law firm) (the “Firm”) and/or to any of its agents or designees, copies of any and all documents and recorded information concerning the undersigned, including, but not limited to, copies of all records and reports relating to any public aid, welfare, unemployment compensation, or any other governmental assistance benefits of any kind that were applied for or received, applications for any public assistance, administrative records regarding any review and determination of need for public assistance and benefits, records regarding all benefits and services provided, any caseworker reports, benefit histories, wage record files, health and physical examination records, as well as copies of all records relating to health, including reports, questionnaires, birth records and certificates, marriage records and certificates, death records and certificates, all physician, hospital, medical, psychiatric and health reports, records relating to any claim filed in connection with any illness, condition, injury or disease or the treatment thereof, or any death benefit, and any records of any administrative hearings and/or litigation, such as pleadings, deposition transcripts, interrogatory responses and any other forms of discovery as they may request information or documents pertaining to the undersigned.
This authorization includes the authority to inspect and copy any and all such records.
The authorization is deemed to be continuing in nature and shall be given full force and effect to release any and all of the foregoing information that is obtained, learned, or determined after the date hereof.
The authorization also releases you from any and all liability in connection with the disclosure of records, documents, writings and any physical evidence made to the Firm or any of its agents or designees.
A copy of this authorization may be used in place of and with the same force and effect as the original.
This authorization shall expire (insert term of authorization) after it is signed.

Name:
Date of Birth:
Social Security No.:
Address:
Signature:

Subscribed to and sworn before me this
______ day of _____________, 200_.

Notary Public
My Commission Expires: