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AUTHORIZATION TO RELEASE INFORMATIONTo Whom It May Concern:You are hereby authorized to release to Mutschall Law PLLC, P.O. Box Street Address , or an authorized representative, all information and records concerning: Patients Name:Patients DOB:Patients Social Security Number: Patients Address:Patient authorizes the custodian of records of, or other person/entity located at, to disclose/release the following information:1. All medical and hospital information, including but not limited to: all history, examinations, diagnoses, prognoses, prescriptions, laboratory records and reports, x-rays, and x-ray readings and reports;2. Medical bills, statements of charges and a report of all expenses associated with your treatment related thereto;3. Physical health, mental health, psychiatric, and psychotherapy data; 4. Educational records, including test results, grades, guidance counselors records, student evaluations, disciplinary notations;5. Employment history, including but not limited to: dates of employment, job titles and descriptions, wages or salary, dates and hours worked, absences from employment and reasons therefore, retirement or termination of employment and reasons therefore, etc.; 6. Military records;7. Any claims presented by Patient or on her behalf for health or medical insurance benefits, or government sponsored program, whether federal, state or local. The reason or purpose for this release of information is: FOR LEGAL PURPOSES. I understand that information disclosed regarding this authorization may be re-disclosed to additional parties and may no longer be protected. This authorization will expire one hundred and twenty (120) days from the date signed below. I am under no obligation to sign this authorization and my ability to obtain treatment will not depend in any way on whether I sign this authorization or not. I have a right to inspect and to request a copy of any information disclosed pursuant to this authorization. By reason of fact that such information that you have acquired as my physician or surgeon is confidential to me, I also request you to treat such information as confidential and request you not furnish any of such information in any form to anyone, without written authorization from me. This authorization should apply not only to present care and treatment being given to me, but should also include both past and future services. This authorization shall serve to revoke all previous authorizations given to you and this authorization shall continue in effect until it is revoked in writing. I have the right to revoke this authorization at any time by writing to eh health care provider listed above. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. I further understand that any revocation does not apply to information already disclosed.I acknowledge that there may be a charge to me for your expenses in connection with preparing copies of your records and in providing your report to my attorney. I hereby agree to reimburse you for any reasonably necessary costs incurred in this regard as provided by law. A copy of this authorization may be submitted for an original for all purposes:SignaturePrinted NameDate