![](https://www.pdfsearch.io/img/2d39c9a50746bc9f3659af0cc52052b7.jpg) Date: 2012-01-27 11:48:39
| | AUTHORIZATION FOR RELEASE OF INFORMATION Patient:_______________________________ TO WHOM IT MAY CONCERN: You are hereby expressly authorized to release and furnish to the State Office of RiskAdd to Reading ListSource URL: www.lamar.eduDownload Document from Source Website File Size: 106,01 KBShare Document on Facebook
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