AUTHORIZATION AND RELEASE FOR GOVERNMENTAL AGENCY RECORDS AND REPORTS I do hereby authorize any federal or state governmental agency to furnish to _________________________ and any of its agents,copies of any and all recorded information, including by way of example, but not limited to the following: Complete copies of all records and reports relating to any disability, unemployment compensation, welfare, public aid or assistance benefits of any kind applied for or received; complete copies of all records relating to health including but not limited to applications, statements, communications, reports, questionnaires, vital statistics, birth records and certificates, marriage records and certificates, death records and certificates, investigatory reports and records, all physician, hospital, medical, psychiatric and health reports, test results, opinions, x-rays and other records; records relating to any claim filed in connection with any illness, sickness, condition, injury or disease or the treatment thereof, or death benefit; and records of all hearings or litigation, including all pleadings,deposition transcripts, interrogatory answers and other forms of discovery. This authorization also includes the authority to inspect and copy any and all such records. This authorization is containing in nature and is to be given full force and effect to release any and all of the foregoing information learned or determined after the date hereof. A copy of this authorization may be used in place of and with the same force and effect a the original.
Dated:_________________________ ______________________________ Date of Birth ______________________________ Social Security Number
______________________________ Print Name:____________________
Sworn to before me this ______ day of _________, 20___.
_______________________________ Notary Public