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MEDICAL AUTHORIZATION


TO:  [NAME OF DOCTOR]

RE:  [NAME OF PATIENT]


You are hereby authorized and directed to furnish to [NAME AND ADDRESS OF RECIPIENT OF MEDICAL RECORDS] copies of any clinical notes and medical records prepared by you relating to the above patient.

You are requested not to disclose any other information to any other persons without my written authority to do so.

Dated: [DATE]

_______________________________

[NAME OF PATIENT]

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