I authorize the release of medical records as follows:
This authorization expires 30 days from the date of the signature below. I understand that I may revoke this authorization at any time with a written, signed and dated notice. However, disclosures made prior to the revocation will not be affected. A copy of this authorization may be used in place of the original with the same effectiveness. I understand there may be fees associated with making copies and mailing these records.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
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