Patient's Name:       Date Of Birth: 
   Previous Name:     Social Security#: 

   I request and authorize  to
   release health care information of the patient named above to

             Name: 
          Address: 
             City:   State:  Zip:
  This request and authorization applies to:
   Health care information relating to the following treatment, condition, or 
      dates:
                  
   All health care information
   Other
            


  patient's Signature:---------------------------- Date Signed:---------------- 

 
    ******** THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED. ********