COMPENSATION CLAIMS SOLUTIONS

1287 OLD CHARLOTTE ROAD

CONCORD, NC 28027

PHONE 704-786-9624

FAX 704-786-9821

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

PATIENT:
DOB:
SSN:
   
This authorization or a photocopy thereof, which is unlimited as to time, will authorize you to release to Compensation Claims Solutions or their appointed representative, all information in your possession regarding my medical records.
   
SIGNATURE   DATE
   
Please list the names and address of all physicians who have treated you in the last 5 years.