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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I,

HEREBY AUTHORIZE THE

RELEASE OF PATIENT’S MEDICAL RECORDS TO:

Please release the following:

I consent to the release of information related to HIV/AIDS or infection with any other

communicable diseases and information related to behavioral or mental health services and

treatment for alcohol and drug abuse, with the rest of the medical records

PURPOSE OF DISCLOSURE

I understand that I may revoke this authorization in writing at any time. Otherwise, this

authorization shall remain valid until such time as it is revoked in writing.

Thanks for submitting!

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