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t t 4 <br /> t••••-•-•! •46.4•4t•••y w••-•p v, JuuOLnl!LC u.e!LUUIIJCIII tU I C!Cll di'dllu/UI d IIIJLUf Y UI ICJLlIl UI UCdUlICId, <br /> acquired,iimmune deficiency syndrome. <br /> AlsoI understand that I may revoke this authorization at any time by notifying the City of Everett in writing,and tF <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 /> WSj-- 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 k orizing Individual: <br /> • <br /> Date Si azure: `Cl <br /> Telephone Number: k. ' <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 /> (e) <br />