AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION 

TO WHOM IT MAY CONCERN 

You are authorized to release to: ________________________, any
and all medical  records related to treatment which I may had on
the following  approximate dates: 
________________________________________________________________

A photocopy of this authorization shall have the same force and 
effect as an original. 


________________________________________________________________


__________________________________ 


Social Security Number: __________________ 

Date of birth: ___________________________