PITTS & ASSOCIATES
and
MALONEY, MARTIN & MITCHELL, L.L.P.
Attorneys at Law
AUTHORIZATION FOR MEDICAL INFORMATION
My signature herein authorizes physicians, hospitals and any and all other health care providers to furnish full and complete medical records concerning the undersigned to my attorneys, PITTS & ASSOCIATES and MALONEY, MARTIN & MITCHELL, L.L.P., or to any representative of their offices. These documents are needed in litigation concerning my injuries received during the 1991 Gulf War.
This Authorization also includes examination of all hospital records and x-rays and the furnishings of any and all information, including opinions, which will or might aid the attorneys named above in the prosecution of claims against the entities liable for injuries sustained by me.
Please do not disclose the above named information to any insurance adjuster or any other person without retaining additional written authority from me. A photocopy of this authorization issued by PITTS & ASSOCIATES and MALONEY, MARTIN & MITCHELL, L.L.P., on my behalf, is acceptable as a medical authorization as stated herein.
AUTHORIZATION FOR MEDICAL INFORMATION