West Palm Beach Florida car accident information request from the Department of Health Call 1-800-74-TRIAL
(Address)

Dear Sir or Madam:

I have retained the West Palm Beach Florida car accident Law Firm of (name and address of law firm) (the “Firm”) to represent me in proceedings to which I am a party. I hereby authorize the Firm to secure and obtain all Department of Health records relating to my personal, medical and health history.
Any and all previous authorizations I may have given are hereby revoked and canceled forthwith, and this authorization shall remain in full force and effect unless and until revoked by me in writing.
I am willing that a photocopy of this authorization have the same force and effect as the original.

_______________________ ______________________________
WITNESS (Name of Client)
(Address of Client)

Subscribed to and sworn before me this ____ day of _______, 200_.

______________________________
NOTARY PUBLIC