Release of Information

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					                     RELEASE OF NON-MEDICAL INFORMATION



To: __________________________________________________________________________

Address: ______________________________________________________________________

            ____________________________________________________________________

Re: ___________________________________________________________



       I authorize you to release and give to _________________________________________

any information which he or she requests concerning ___________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

I waive any privilege I may have regarding that information.


Dated: __________________, 20____           ________________________________________
                                                   Signature

                                            ________________________________________
                                                   Printed Name
Address: _____________________________________________________________________________
Telephone: _______________    Fax: ___________________         E-Mail: _____________________




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