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OF INJURY OR LAST EXPOSURE: FIRST DESIGNATED PHYSICIAN: Name Street Address ( City, State, Zip ) Telephone Number Accepted by: MEDICAL INFORMATION RELEASE: I hereby waive any privilege I may have to restrict the release of information or written material reasonably related to the work-related injury/disease for which I have sought treatment, and I consent to the release of this information or written material to the medical payment obligor, my employer, Special Fund, Uninsured Employers.

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