AUTHORIZATION TO DISCLOSE INSURANCE INFORMATION FOR LITIGATION PURPOSES

By signing this Authorization, I hereby authorize (INSURANCE

(Policyholder/Client)
1. I authorize the entire insurance record related to the Policyholder to be used or disclosed as set forth in
this Authorization.
2. I authorize this information to be disclosed to the attorney with the following name and address:
3. I authorize this information to be disclosed to the attorney named above for the purpose of assisting with
certain legal matters.
4. I understand that I have the right to revoke this Authorization at any time in writing, except to the extent
that the above-referenced INSURANCE PROVIDER has already acted in reliance on the
Authorization. I can revoke this Authorization by providing a written revocation to the
INSURANCE PROVIDER.
5. I understand that the INSURANCE PROVIDER may not condition treatment, payment, enrollment or
eligibility for benefits on whether I sign this Authorization.
6. I understand that information used or disclosed pursuant to this Authorization may be subject to
re-disclosure by the recipient and no longer subject to applicable privacy laws.
7. This Authorization shall be effective for the entire duration of legal matters related to the accident which
involved the patient and occurred on ______________________ (date of accident).

Authorization from Policyholder Authorization from Person other than Policyholder

____________________________ ______________________________________
Signature of Policyholder Signature of Person other than Policyholder
____________________________ ______________________________________
Printed Name of Policyholder Printed Name of Person other than Policyholder
____________________________ ______________________________________
Date Legal Relationship to Policyholder
(Attach Documentation)
__________________________________
Date
__________________________________
Street Address/P.O. Box of Person making Authorization
__________________________________
City/State/Zip Code of Person making Authorization
__________________________________
Telephone Number of Person making Authorization

STATE OF FLORIDA
COUNTY OF LEE

SWORN TO and Subscribed before me this _______ day of ___________, 20___ by

__________________________
Notary Public