(The execution of this form does not authorize the release of information other than the terms specifically
I request and authorize the above-named doctor or health care provider to release the information
specified below to the organization, agency or individual named on this request. I understand that the
information to be released includes information regarding the following condition(s):
PURPOSE OR NEED FOR WHICH INFORMATION IS TO BE USED:
may not be used with the same effectiveness as an original.
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