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CONSENT FOR RELEASE OF MEDICAL INFORMATION

    To the attention of:

    Patient Last Name:
    First Name:
    Middle Name:

    Address:

    City:
    State:
    Zip:

    Birth Date:
    Social Security:

    I HEREBY AUTHORIZE the above stated facility to release copies of my medical records to Bay Area Endocrinology Associates for the purpose of assisting in the care and treatment of my medical condition.

    I AUTHORIZE release of information covering treatment dates of through and including

    I HEREBY RELEASE the said facility from any liability which may arise as a result of my authorization to release the foregoing records. This authorization covers all my medical records and treatments during the dates indicated.

    Patient (or person authorized to consent for a minor or patient who is unable to sign due to a physical or mental incompetency):

    Date:

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