Medical Clinic Record Release Form

I HEREBY AUTHORIZE AND REQUEST YOU TO RELEASE TO:

THE FOLLOWING: ______________________________________________________
_____________________________________________________________________
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REASON FOR REQUEST: _________________________________________________
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NAME: _______________________________________________________________
ADDRESS: ____________________________________________________________
DATE OF BIRTH: ______________________________________________________

SIGNATURE: __________________________________________________________
RELATIONSHIP: _______________________________________________________
DATE: _______________________________________________________________
WITNESS: ____________________________________________________________

THIS AUTHORIZATION TO BE EFFECTIVE FOR ONE YEAR FROM THE DATE OF SIGNATURE