LAW OFFICES OF

VINCENT W. DAVIS & ASSOCIATES

VINCENT W. DAVIS, ESQ.
Founder

ATTORNEY S AT LAW

ROBERT GRANIERI, ESQ., Of Counsel ELIZABETH BRICEO-VELASCO, ESQ. MARK L. TSESELSKY, ESQ. NORMA NOGUEDA, ESQ. ARSHAK BARTOUMIAN, ESQ. LINDA M. NAKAMURA, ESQ. CAROL A. BAIDAS, ESQ.* DANIELLE K. LITTLE, ESQ.** GRADY TALBOT, ESQ. JAMES W. HOLCHIN, ESQ. JODY KOLIKIAS, Financial Supervisor

WWW.VINCENTWDAVIS.COM

150 N. SANTA ANITA AVE. SUITE 200 ARCADIA, CA 91006 P: 626.446.6442 F: 626.446.6454 9595 WILSHIRE BLVD. SUITE 900 BEVERLY HILLS, CA 90212 P: 310.724.8163 F: 310.724.8167

ESTABLISHED 1999
*ADMITTED TO PRACTICE LAW IN CALIFORNIA AND PENNSYLVANIA **ADMITTED TO PRACTICE LAW IN CALIFORNIA AND NEW YORK

AUTHORIZATION TO DISCLOSE INFORMATION

This will authorize all doctors, hospitals, clinics, or other medically related facilities, insurance companies, employers, governmental agencies, and/or any and all persons or institutions to whom this may be presented, to disclose to my

attorney, The Law Offices of Vincent W. Davis & Assoc. , or to his authorized representatives, any and all documentation, records, information and reports, including any and all psychiatric and/or psychological records and/or billings, concerning me, or drug/alcohol abuse information, or any other matter in which I am interested, including the nature, extent, duration and treatment of my injuries, or those of any member of my family, all as fully and as freely as they would disclose the same to me, personally, it being my intent that this authorization is to serve as my consent to a full disclosure of any and all information to my attorneys, in any circumstances where my consent may be requested or required. Any information obtained will not be released by my attorneys except to persons or organizations performing investigative, legal or medical services for my attorneys, or persons or organizations who are parties to or directly interested in the litigation. An electronically transmitted copy of this Authorization shall be considered as effective and valid as the original and shall remain effective for two years from the date of Authorization. I also authorize my attorney to obtain the release of police reports and/or reports of the Highway Patrol. DATED: . . [Client] Social Date Security of # Birth:

. .

NOTICE
California Evidence Code (Section 1158): "Failure to make such records available, during business hours, within five (5) days of presentation of written authorization, may subject the person or entity having custody or control of the records to liability for all reasonable expenses, including attorneys' fees, incurred in any proceeding to enforce the provisions of this section."