Accident Report Form

This electronic signature is authorization for any and all Health Care Providers, including but limited to Hospitals, Clinics, Physician Offices, Diagnostic Centers and Therapy Facilities.

I , the undersigned, hereby authorize the Custodian of Records of health care providers to which this authorization has been directed to release any and all information which may be requested regarding myself and to photocopy any records regarding me, including records which have been maintained regarding my past or present physical or mental condition and treatment rendered, including but limited to my consumption of alcohol or use of drugs including those protected under Title 242 of the Code of Federal Regulations, Part 2; Psychological or Psychiatric records, including communications made by me to a social workers, psychologist or psychiatrist; including behavioral or mental health services.

All records for any and all dates of evaluation, care or treatment to be disclosed.

Make disclosure to: York, Risk Services Group, Inc. PO Box 620 Howell, MI 48844‐0620

The purpose and need for disclosure is: At the request of the undersigned to process the above reference claim.

As a claimant, I may revoke this authorization by notifying the Custodian of Records of applicable health care provider in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

This authorization expires one year from the date of execution.

A PHOTOCOPY OR DIGITALLY SHARED COPY OF THIS DOCUMENT SHALL BE CONSIDERED VALID AS IF THE ORIGINAL WERE OFFERED.