Retainers:

Retainer PI

Retainer PI/WC

Retainer WC

Retainer WC/RL

BWC forms:

R2 – Authority to Represent

c230

C240 – Application for Settlement

Wage Statement

 

Medical Releases/Authorizations

Auth PI

CCF Authorization

https://thefriedmanlawfirm.com/e-signature-document/uh-authorization/

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: 

Date of Birth: 

SSN:  

Leave this empty:

The Friedman Law Firm https://thefriedmanlawfirm.com
Signature Certificate
Document name: Authorization
Unique Document ID: d13855b792269e97da59b5680e7b57fdb66e62aa
Timestamp Audit
August 25, 2017 1:02 pm ESTAuthorization Uploaded by Kristin Cool - kcool@thefriedmanlawfirm.com IP 98.103.108.218