Auto Insurance Authorization

I hereby request and authorize my auto insurance carrier to release my auto insurance information and health record to WeCare Medical Specialty Group. The information includes but is not limited to:

1. 1) Declaration Sheet
2. 2) PIP coverage limits
3. 3) Updated PIP ledger
4. 4) IME report (N.J.A.C 11:3-4.7 (e)(6))
5. 5) PIP benefit exhaustion Letter

I hereby also request and authorize my healthcare carrier, my treating physician and doctor, and lab to disclose, make available and furnish to WeCare Medical Specialty Group all information including: healthcare insurance, medical records, X-rays, MRI report, IME report and/or copies thereof related to my examination, confinement of treatment and to permit WeCare Medical Specialty Group to inspect and make copies, or abstracts thereof.

Note: If these records contain any information from previous providers or information about HIV/AIDS status, cancer diagnosis, drug/alcohol abuse, or sexually transmitted disease, you are hereby authorizing disclosure of this information.

Please send the records by fax, mail or email to:

2040 Millburn Ave #201, Maplewood, NJ 07040
Phone: 973-996-2990 Fax: 908-242-3911
Email: officemanager@wecaremedical.us

I further understand this authorization is voluntary and that I may refuse to sign this authorization. By signing below I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information to WeCare Medical Specialty Group.

Patient Signature: