PHILLIP L.

WEINBERG
ATTORNEY AT LAW
14241 NE Woodinville-Duvall Rd., #385
Woodinville, WA 98072-8564
Tel.: (425) 806-7200; Cell: (425) 367-1122; Fax: 425-745-1200
Email: phil@weinbergDUI.com

AUTHORIZATION FOR RELEASE OF INFORMATION

Patient Information:

________________________________________________________________
(PRINT name of Patient) DOB SS#

Information to be released from:

________________________________________________________________
Name of designated Facility or Provider

________________________________________________________________
Address

I request and authorize the above name facility or provider to release health care
information of the patient named above to:

PHILLIP L. WEINBERG, Attorney at Law

14241 NE Woodinville-Duvall Rd., #385
Woodinville, WA 98072-8564
Tel.: (425) 806-7200
Cell: (425) 367-1122
Fax: (425) 745-1200

Information to be Released:
[ ] The most recent 2 years of pertinent information (chart notes, labs, x-rays, and special
tests)

[ ] All Medical Records

[ ] All Medical Billing Records

[ ] Specific Information -- Only the following:

ALL MEDICAL AND MEDICAL BILLING RECORDS, including but
not limited to, chart notes, labs, x-rays, and special tests pertaining to the
Motor Vehicle Accident or collision involving the patient that occurred in
_____________________________ County, Washington on or about
________________________, FOR THE FOLLOWING DATES OF
SERVICE:
____________________________________________________
____________________________________________________
____________________________________________________.

1
Purpose for which disclosure is being made:
[ ] Attorney / Legal evaluation; and/or
[ ] Insurance / Claim evaluation

Patient Authorization:
I understand that my express consent is required to release any health care information relating
to testing, diagnosis and/or treatment for HIV (AIDS Virus), sexually transmitted diseases,
psychiatric disorders, mental health or drug and/or alcohol use. Wherefore, if I have been tested
diagnosed or treated for HIV (AIDS Virus), sexually transmitted diseases, psychiatric
disorders/mental health, or drug and/or alcohol use;

[ ] You are hereby specifically authorized to release all health care information relating to
such diagnosis, testing or treatment.

[ ] You are hereby not authorized to release any health care information relating to such
diagnosis, testing or treatment.

My Rights:
I understand I do not have to sign this authorization in order to obtain health care benefits
(treatment, payment or enrollment). I may revoke this authorization in writing except to the extent
information may have already been disclosed pursuant to this release. I understand that once the
health information I have authorized to be disclosed reaches the noted recipient (my attorney, Mr.
Weinberg), then he (Weinberg) may re-disclose it, at which time it may no longer be protected
under Privacy laws.

Reasonable Fee:
State law provides that a health care provider may charge a reasonable fee for the requested
records.

_____________________________________________ _____________________
Signature of Patient (or Patient's Authorized Representative) Date Signed

This Authorization shall automatically expire 90 days from the date signed.