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Document ID: df9aac566cea70342ef1b34b74e2620055deb64d
May 4, 2017
Signed On : https://thefriedmanlawfirm.com

Medical Authorization - WC - todd sells


CLIENT AUTHORIZATION

(Copy to Serve as Original)

TO:

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

Other:  

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: todd sells

Date of Birth: 04/11/1963 

Social Security Number: 292722805

Signed by todd sells
Signed on: May 22, 2017

Signature Certificate
Document name: Medical Authorization - WC - todd sells
Unique Document ID: df9aac566cea70342ef1b34b74e2620055deb64d
todd sells
Party ID: bb4e9123-cc5b-4d45-aa10-9dfa0abee14b
IP Address: 172.12.172.201
Security Level: E-mail
Digital Signature:
todd sells
Multi-Factor
Digital Fingerprint Checksum
7469bf1671d1f9ee1a50db05e2b2569c
Timestamp Audit
2017-05-04 13:23:18 EDTMedical Authorization - WC Uploaded by Kristin Cool - kcool@thefriedmanlawfirm.com IP 98.103.108.218
2017-05-22 17:29:42 EDTDocument viewed by todd sells - tsells1963@att.net IP 172.12.172.201
2017-05-22 17:34:47 EDTDocument signed by todd sells - tsells1963@att.net IP 172.12.172.201
2017-05-22 17:34:47 EDTThe document has been signed by all parties and is now closed.
2017-05-22 23:04:38 EDTDocument viewed by todd sells - tsells1963@att.net IP 54.92.175.204