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WordStar Document  |  1993-08-01  |  896b  |  26 lines
  1.  
  2. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION 
  3.  
  4. TO WHOM IT MAY CONCERN 
  5.  
  6. You are authorized to release to: ________________________, any
  7. and all medical  records related to treatment which I may had on
  8. the following  approximate dates: 
  9. ________________________________________________________________
  10.  
  11. A photocopy of this authorization shall have the same force and 
  12. effect as an original. 
  13.  
  14.  
  15. ________________________________________________________________
  16.  
  17.  
  18. __________________________________ 
  19.  
  20.  
  21. Social Security Number: __________________ 
  22.  
  23. Date of birth: ___________________________ 
  24.  
  25.                            
  26.