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L'r"""'! Wll-P+I.-+4 LIP V1.11C1 L.UI ru Utieu JUUJLaHHLe UJC,LJUuselirrg ICrtLndrJ.a11u/ur @ nrstory o Leslrng ui liedurtelil in' '• <br /> acquired immune deficiency syndrome. <br /> 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 tl a 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 /> S l 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 Authorizing Individual: • <br /> • <br /> • <br /> Date of Signature: (<Ctrt.1.it?A <br /> Telephone Number: d^,307 <br /> Witness(where patient is over 13 and signing the release): <br /> Where the signer is not the subject of the records: <br /> I am authorized to sign this because I am the(attach proof of authority): <br /> ❑ Parent 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 /> c/o Legal Department • <br /> 2930 Wetmore Ave,Suite 10-C <br /> Everett,WA 98201 <br /> • s <br />