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acquired immune deficiency syndrome. <br /> —D,A.C" i understand that I may revoke this authorization at any time 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 /> I understand that this Authorization for Release will be valid until my claim is resolved or closed by the City. <br /> (Initial) <br /> A copy of this Authorization carries the same authority'as the original for purposes of releasing my records to the City. <br /> Signature of Autho1izing Individual: - <br /> %tek <br /> Date of Signature: I " ) — 13 <br /> Telephone Number: S � �' , � <br /> Witness(where patient is over 13 and signing the release): <br /> Where the signer is not the subject of the records: <br /> l am authorized to sign this because I am the(attach proof of authority): V <br /> ❑ Parent of Minor <br /> El Legal Guardian <br /> ❑ Personal Representative <br /> 111 Other <br /> To the Provider or Records Custodian: <br /> Please send legible copies of all records to: <br /> City of Everett <br /> do Legal Department <br /> 2930 Wetmore Ave,Suite 10-C <br /> Everett,WA 98201 <br />