Sample Of An Authorization and Consent of Information Form Requesting Medical Records In A Personal Injury Accident

If you have been injured in an accident and are filing a personal injury lawsuit, your attorney will need to request your medical records.

Below is a sample of an HIPAA Authorization and Consent of Information form that we filed on behalf of our client authorizing the release of all their medical records-mental health records, billing statements, radiological films, pathology material, photographs, videos, and other information-to our firm. This document also allows our client’s medical provider to verbally disclose information about our client’s diagnosis, treatment, and prognosis. We have redacted the names of our client and their medical provider for purposes of confidentiality.


Medical records can provide evidence regarding the extent of your injuries. They can also help determine the amount of compensation you should claim. Getting a medical expert to testify in court about your injuries can also help your case.

This Document was provided by the personal injury law firm of Lebowitz and Mzhen. For more information, call 1-888-311-HURT or send an email.

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