RECORDS AUTHORIZATION

TO WHOM IT MAY CONCERN:

I hereby request and authorize you to furnish Claims & Risk Services, Inc. or their representative                                                                , any and all information you may have concerning me, with respect to any illness or injury, medical history, consultation, prescription or treatment, including x-rays, and copies of all hospital records.

I give Claims & Risk Services, Inc. permission to access any workers compensation claims information by using my name and/or my Social Security Number which is                       -               -                     .

A photostatic copy of this authorization shall be considered as effective and valid as the original.

NOTICE

The information authorized for release may include information regarding a communicable or venereal disease which may include, but are not limited to, diseases such as hepatitis, syphilis, gonorrhea, and human immunodeficiency virus also known as Acquired Immune Deficiency Syndrome (AIDS).

Signed on this                 day of                         , 2000 at                            , Oklahoma.

Signed                                                     

                                                    
(Name typed or printed)