Authorization to Release Records

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4/9 EXAMPLES

Text in this Example:

You are hereby Authorized and requested to furnish to
or his representative, all my medical and drug records (including x-rays, if any), and reports, abstracts, and summaries thereof, accident and/or police reports, employment and earnings, histories and records, bills and statements, and all other information pertaining to me, to permit them to examine all originals and to make copies thereof.
DATE
NAME
ADDRESS
Authorization to Release Records