| Patient Name: ______________________ | Health Record Number: _______________ |
| Date of Birth: ______________________ | S.S. No.: ___________________________ |
1. I authorize the use or disclosure of the above named individual’s health information as described below:
2. The following individual or organization is authorized to make the disclosure:
Name: __________________________ Address: _________________________________
3. The type and amount of information to be used or disclosed is as follows: (include dates where appropriate)
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