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Form53 - [FORM 53-Use the top of this page for your...

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[ FORM 53 —Use the top of this page for your letterhead.] Authorization to Release Confidential Information to an Attorney I do hereby authorize you, the clinician named in the letterhead above, to furnish to , my attorney, at , with a full report of your examination, diagnosis, treatments, prognosis, and any other records concerning me/the patient named in regard to the accident/incident/condition for which I/the patient sought your services, which began on . I authorize you, the clinician, to answer any and all questions or other requests for information from my attorney regarding my/this patient’s treatment by you, and to appear and to testify regarding my/this patient’s treatment and records at depositions or in court or any administrative proceedings. I completely waive and release any rights of confidentiality I may have concerning these records and information, and agree to hold the clinician harmless and to indemnify him or her from any and all claims made against him or her in connection with the release or transfer of these records and information as here authorized.
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