Authorization to Release Information

In order to obtain information about your case, we need your authorization to release your case documents and information to us. We cannot proceed without it.

Dear

Enter your ATTORNEY’S NAME HERE:   

I hereby authorize and direct you, and/or your successors, to release to Lawsuit Cash, and/or their successors, any and all information, whether oral or otherwise, that pertains to my case for the purpose of evaluating my claim.  I also specifically waive any privilege that I may have in this regard and request that my attorney share his/her candid opinion of my case with Lawsuit Cash.

I understand that authorizing the disclosure of protected health information is voluntary.  I can refuse to sign this authorization.  I need not sign this form in order to assure treatment.  I understand I may inspect or copy the information to be used or disclosed, as provided under HIPAA compliance regulations.

I acknowledge that I understand the benefits and costs of non-recourse funding.  I further acknowledge I understand the effects of disclosing the contents of my file, including waiver of the attorney-client and work product privileges and agree to release Lawsuit Cash, and/or their successors fully and completely from any claim that may arise by reason thereof.

Thank you in advance for your cooperation in this matter.

Enter your FULL NAME here:   

Enter TODAY'S DATE here:      

   By clicking here you indicate that you have read and agree to the Authorization for Release of Information.  You must check this box to have your application processed. This gives us permission to contact your attorney and review your file.  All information is held strictly confidential.

By submitting this form I agree that all the information listed is accurate to the best of my knowledge.