In the near future we will be doing reviews and listing service providers that offer risk analysis and underwriting solutions. As well has life expectancy companies.

Authorization Form

LIFE PROJECTIONS
5905 Leeds Rd.
Hoffman Estates, Il. 60192
847.874.3611

AUTHORIZATION FORM
I hereby authorize any physician, medical practitioner, hospice, hospital, clinic, or other medical or medically related facility, pharmacy, or any other institution or person (each a “Medical Provider”) to provide to LIFE PROJECTIONS, or its representatives, advisors, employees, successors or designees, any and all information as to diagnosis, treatment and prognosis with respect to any physical or mental condition including HIV, AIDS, AIDS related complex, psychiatric conditions, or drug or alcohol abuse of or relating to me.
I further understand and confirm that this authorization allows for the disclosure, inspection and copying of any and all records, reports or documents, including any underlying data, regarding my care or treatment, and any other information in such Medical Provider’s possession concerning my condition, treatments or hospitalization, including, but not limited to, all testing materials completed by or administered to me, along with any and all medical charts, clinical or doctor’s notes, memoranda, medical records, x-ray reports, index cards, history notes, picture records and medical bills in such Medical Provider’s possession and control.
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Signature
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Date
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Print Name
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