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Document ID: 31722d85227b1ecfafc610caa997737805c509c4
September 22, 2017
Signed On :

Medical Authorization - WC - Roslyn Devaux Spitzley

(Copy to Serve as Original)
I hereby authorize the above to disclose to THE FRIEDMAN LAW FIRM at 3401 Enterprise Pkwy., Suite 330, Cleveland, OH 44122 the following:
Medical records – Dates of service 
Itemized bills – Dates of service 
Narrative report
Prescription records
Police report
I understand I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire two years from the date signed below. If I fail to specify an expiration date, event, or condition, this authorization will expire in six months. I understand that the requested information may contain information concerning treatment for a sexually transmitted disease, alcohol, drug abuse, a psychiatric condition, or HIV test results, and AIDS diagnosis, or AIDS related condition.
I understand that some or all of the requested information provided to The Friedman Law Firm may be redisclosed to organizations which, and persons who, are not subject to federal and state protected health information privacy laws, and therefore that redisclosure by these organizations or people may not be protected by such laws.
I understand that treatment and payment may not be conditioned or revoked as a result of signing this authorization.
Name: Roslyn Devaux Spitzley
Date of Birth: 10/06/1954 
SSN: Not by email 

Signed by Roslyn Devaux Spitzley
Signed on:September 22, 2017

Signature Certificate
Document name: Medical Authorization - WC - Roslyn Devaux Spitzley
Unique Document ID: 31722d85227b1ecfafc610caa997737805c509c4
Roslyn Devaux Spitzley
Party ID: df3677b9-2cb4-4300-84f0-02141e39d012
IP Address:
Security Level: E-mail
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Digital Fingerprint Checksum
Timestamp Audit
2017-09-22 13:42:36 EDTMedical Authorization - WC Uploaded by Kristin Cool Cool - IP
2017-09-22 13:42:36 EDTDocument viewed by Roslyn Devaux Spitzley - IP
2017-09-22 13:43:16 EDTDocument signed by Roslyn Devaux Spitzley - IP
2017-09-22 13:43:16 EDTThe document has been signed by all parties and is now closed.
2017-09-25 18:15:35 EDTDocument viewed by Roslyn Devaux Spitzley - IP