FROM:

 

 

 

 

 

DIRECTED TO:

 

 

Re: CLIENT:                            DATE OF BIRTH:

SOCIAL SECURITY #:

D/L #:

 

TYPE OF RECORDS REQUESTED:

 

*****************************************************************

AUTHORIZATION TO RELEASE INFORMATION/RECORDS

 

 

You are hereby authorized to release any and all records or to speak to any authorized representative of:

 

concerning my records.  California Evidence Code Section 1158 provides that records under your custody or control be made available for inspection or copying upon presentation of a written authorization.

 

FAILURE TO MAKE SUCH RECORDS AVAILABLE DURING BUSINESS HOURS, WITHIN FIVE DAYS AFTER PRESENTATION OF THE WRITTEN AUTHORIZATION, MAY MAKE THE ENTITY OR PERSON HAVING SUCH CUSTODY OR CONTROL OF THE RECORDS SUBJECT TO LIABILITY FOR ALL REASONABLE EXPENSES, Including ATTORNEY’S FEES INCURRED IN ANY PROCEEDING TO ENFORCE THE PROVISIONS OF THIS EVIDENCE CODE.

 

 

 

           A PHOTOCOPY OF THIS SIGNED AUTHORIZATION SHALL

                 BE DEEMED AS VALID AS AN ORIGINAL.

 

 

 

Date:                     By: