AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO WHOM IT MAY CONCERN

You are authorized to release to:______________, any and all medical records and treatment which I may had on the following approximate dates:

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A photocopy of this authorization shall have the same force and effect as an original.

Name:________________________________________

Address:______________________________________

______________________________________________

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Social Security Number:__________________________

Date of Birth:___________________________________

Date:__________________________________________