This authorizes all physicians, hospital and medical attendants to furnish full and complete medical reports and information hereby requested by the undersigned to the law firm of KERRIGAN, ESTESS, RANKIN & McLEOD, 400 East Government Street, Pensacola, FL 32501, or to any representative, attorney, or investigator from said office, and especially any and all medical reports concerning injuries received as a result of an incident or illness which occurred on or about.

This authorization also includes access to and examination of all hospital records, office notes, x-ray films, x-ray reports, bills and/or itemized statements, and the furnishing of any information, including opinions, resulting from my medical care at any time prior to or including the date above and all subsequent medical care to the present date which will aid the said attorneys in their inquiry into matters pertaining to the above incident or illness. I have requested the said law firm to review all pertinent medical information in connection with this matter.

Your full cooperation with these attorneys or their representatives is requested. You are further requested to disclose no information to any other person without written authority from me to do so.

ALL PRIOR AUTHORIZATION IS HEREBY CANCELLED.

DATED this ____ day of ________________ , 19__.

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