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Te of Birth: Address: City: State: Zip Code: (2) Name and address of health provider or entity authorized to release this information: To: Address: City: State: Zip Code: (3) Statement of Authorization and Purpose: I request that health information regarding my care and treatment be released to the CONNECTICUT BAR EXAMINING COMMITTEE, including its authorized staff, agents and representatives, 100 Washington Street, Hartford, CT 06106, which is conducting an investigation into my professi.

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