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k i11ILIoIJ dILU11U1,UIUg Ur ULller WIIU VtIeU JUUJ Ld1 ll.0 U ,LUUIIJCI11%ICICiId1J dIIUt UI d IIWLUly UI LCU11g UI u eau itelu UI <br /> (ir <br /> �,,�yyacquired immune deficiency syndrome. <br /> '"'1fyJ�S I understand that I may revoke this authorization at anytime by notifying the City of Everett in writing,and that <br /> (Initial) the revocation will be effective as of the date the City receives it. Any records obtained pursuant to this <br /> Authorization for Release of PHI prior to the revocation will be deemed authorized by me for release. <br /> y � <br /> /Vl L.S Ma '�,ff I understand that this Authorization forRelease will be valid until my claimis resolved or closed by the City. <br /> (Initial) <br /> t <br /> A copy of this Authorization carries the same authority as the original for purposes of releasing my records to the City. <br /> Signature- <br /> of Authorizing Individual: • <br /> )(5)1 _,. .t. ti <br /> a <br /> Date of Signa4e: q`(s <br /> Telephone Number: 9 6'59 -663J <br /> Witness(where patient is over 13 and signing the release): <br /> Where the signer is not the subject of the records: <br /> • <br /> I am authorized to sign this because I am the(attach proof of authority): <br /> igParent of Minor ' <br /> ❑ Legal Guardian <br /> ❑ Personal Representative • <br /> ❑ Other <br /> To the Provider or Records Custodian: <br /> Please send legible copies of all records to: <br /> City of Everett <br /> d o Legal Department <br /> 2930 Wetmore Ave,Suite 10-C <br /> ' Everett,WA 98201 <br /> ( l,i <br />