Notice Of Tort Claim (Page 8 of 8) in pdf

Notice Of Tort Claim Page 8

statements, bills, reports and documents are the only ones known to me to be in

existence at this time. I am aware that if any statement made is willfully false, I am

subject to punishment provided by law.

Dated:

_________________________________________________________________________

CLAIMANT OR PERSON FILING ON BEHALF OF CLAIMANT

TO WHOM IT MAY CONCERN:

I hereby authorize any and all doctors, hospitals or other medical service facility to

release to the:

City of Atlantic City Solicitor’s Office or its Third Party Claims Administrator or

their representatives, any and all records, reports and other information concerning

the treatment of the claimant named herein.

Dated:

______________________________

Name (written)

______________________________

Signature

(This form must be signed by claimant or the parents of the claimants who are

minors.)

ALL INFORMATION REQUESTED IN THIS FORM MUST BE PROVIDED SO

THAT FAIR AND FULL DISCLOSURE OF INFORMATION NECESSARY TO

THE ORDERLY AND EXPEDIENT ADMINISTRATIVE DISPOSITION OF THE

CLAIM MAY BE HAD. UNDER THE SCHEME OF THE NEW JERSEY TORT

CLAIMS ACT, A GOVERNMENTAL ENTITY IS AFFORDED AT LEAST SIX

MONTHS FROM THE DATE OF THE RECEIPT OF A COMPLETED CLAIM

FOR TO REVIEW AND SETTLE MERITORIOUS CLAIMS.

FAILURE TO

PROVIDE COMPLETE ANSWERS TO ALL QUESTIONS AND/OR THE

WITHHOLDING OF INFORMATION MAY RESULT IN FORFEITURE OF THE

CLAIMANT(S) RIGHTS (N.J.S.59:81, et seq.).

Notice Of Tort Claim Page 8