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On as described below from the records of: Name: Date of Birth: Address: ID number(s) (identify each type of number) Telephone: 2. Reason for disclosure: (Describe each specific purpose - if disclosure is at individual s request and information to be disclosed does not include drug and alcohol treatment information, may state, At the request of the individual ) 3. I understand that: a. this authorization may be revoked at any time by writing to the individual/organization identified in.
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