Records Request Authorization
Form
I herby authorize you to use or
disclose the specific information described below, only for the
purposes and parties also described below.
Description of the specific
information to be used or disclosed:
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Person or entity requesting the
information and authorized to make the requested use or disclosure:
_____________________________________________________________________________________________________________
Recipient of this information:
______________________________________________________________________________________
______________________________________________________________________________________________________________
This information is being requested
for the following purpose(s):
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______________________________________________________________________________________________________________
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This authorization shall remain in
effect form the date signed below.
I understand that: