RECORDS RELEASE AUTHORIZATION

Complete this form for the adult requesting custody / visitation, not the child subject to these proceedings.

NAME: SSN: DOB:

NAME OF REQUESTOR: Weaver Law Services

Margaret V. Weaver, Esquire

P.O. Box 6710

Virginia Beach, VA 23456

I acknowledge that I am signing this form to cooperate with an investigation related to the Guardian ad litem’s investigation in the custody and / or visitation of a minor child(ren). I hereby authorize the recipient of this Release of Information to provide to Weaver Law Services any and all information they, in the exercise of their sole discretion, request concerning my criminal, traffic, civil, chancery, professional licensure and professional regulatory records, including records held at any Juvenile and Domestic Relations District Court, any State or Local government agency, or regulatory or administrative board. This information may include, but is not limited to, any present or past legal or administrative proceedings, litigation, criminal trials and/or hearings (misdemeanor and/or felonies), child neglect and/or endangerment records with the Department of Social Services, child custody, child support and civil suits filed for or against me. I understand and permit any information released to be provided to the court having jurisdiction over said custody and visitation litigation.

You are hereby also authorized to furnish and release to Weaver Law Services all of my Personal Health Information in your possession, control or custody that is requested by them, including, but not limited to any mental health or medical treatment that I have received also including, but not limited to DNA test results, doctors’ notes; nurses’ notes; radiology, pathology, laboratory and other diagnostic test reports; original radiographs; itemized bills; correspondence of any kind to and from any person or entity; and memorandum concerning my examination and testing by you or others at your request; your findings, treatment recommendations and procedures, and medical opinions as to my physical, mental and/or emotional condition in connection on any date of service at your facility.

The purpose of this disclosure is to allow the Guardian ad litem, my child’s attorney, to fully protect my child(ren)’s interests in the custody / visitation matter. Therefore, the disclosed Personal Health Information may be re-disclosed by them as they, in the exercise of their sole discretion, see fit. I understand that this further disclosure by them may act as a forfeiture of my right to privacy concerning this information. I ask that you accept a copy of this Personal Health Information Release Authorization as having the same validity, force and effect as the original. This authorization shall remain in effect for five years from the date of signing said authorization. I understand that I may revoke the limit of the scope of this authorization by notifying the Guardian ad litem, my child’s attorney, at Weaver Law Services at their office in writing of my desire to so revoke or limit the authorization. Furthermore, I do so revoke all authorizations given by me prior to the date of signing this authorization that may be received by you from any person or entity other than the Guardian ad litem, my child’s attorney at Weaver Law Services I understand and permit any information released to be provided to the court having jurisdiction over said custody and visitation litigation.

______________________________ _______________________

Signature Date

COMMONWEALTH OF VIRGINIA

CITY OF _________________, to-wit:

Subscribed and sworn to before me this ______ day of _____________, 201__.

________________________

NOTARY PUBLIC

My Commission expires: _______________

#: _______________