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HIPAA Release Form

HIPAA Release Form

HIPAA Release Form – Authorization For Release of Medical Information

Download and review a blank HIPAA Release Form. This form authorizes third parties to request and retain medical bills and records on your behalf.

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    “I want to brag about my experience!”
    “When my 4-year old son and I were involved in a terrible head-on collision, I wasn't sure where to turn. Wallace Pierce has been great showing me the way!”
    - Mary P.
    “Richard Dingus is a great attorney!”
    “Richard Dingus is a great attorney! And I think the best, serving in the state of North Carolina. I would recommend him for injury and bodily claim any day.”
    - Isaac B.
    “Thank you again for all you did for my family”
    “They were concerned not only about getting our vehicle replaced, but more importantly my kid’s full recovery.”
    - Coral M.
    “I was completely shocked at the amount I received”
    “I retained this law firm to fight my case. I was completely shocked at the amount I received once the case was won.”
    - Schjuana S.
    “They went above and beyond for me!”
    “Mr. Pierce gave me practical advice and was very thorough in guiding me through the process. I left with a strong and positive impression of him.”
    - Audria L.
    “Very knowledgeable”
    “Was able to either point me in the right direction or answer any questions I had regarding the accident I was in. Thank you!”
    - Steven L.
    “Great Law Firm!”
    “Great Law Firm, Friendly Staff, Amazing Service. Willing to help you every step of the way.”
    - Caleb M.
    “Thanking all of the Attorneys and Staff.”
    “I could not recommend anyone any higher than I recommend Wallace Pierce Law, they get the job done and they do it quicker and better and keep you informed along the way.”
    - Debby L.

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Our top priority is to devise customized legal strategies that are tailored to the unique legal needs of our clients, no matter how simple or complicated their situations, might be.

  • $1,900,000 Wrongful Death

    The at-fault driver failed to reduce speed and collided with our client's vehicle. Our client passed away shortly after the collision.

  • $900,000 Wrongful Death

    Our client was thrown from his motorcycle and was pronounced deceased on the scene.

  • $122,000 Car Accident

    Vehicle made a left-hand turn, failing to yield the right of way.

  • $104,000 Serious Injuries

    Client was a passenger in a vehicle that was driving through an intersection when another vehicle ran a stop sign and t-boned the vehicle our client was in.

  • $104,000 Severe Injury

    We were able to not only receive policy limits for our client but were able to negotiate her medical bills and liens to ensure that she was able to keep a good portion of the settlement.

  • $102,000 Serious Injuries

    Elderly client was a passenger in a vehicle that was t-boned in an intersection where a driver failed to yield the right of way.