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acquired immune deficiency syndrome. <br /> tf (3 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 /> cj' Authorization for Release of PHI prior to the revocation will be deemed authorized by me for release. <br /> L0I understand that this Authorization for Release will be valid until my claim is resolved or closed by the City. <br /> cl.s (Initial) <br /> A copy of this Authorization carries the same authority as the original for purposes of releasing my records to the City. <br /> Signatu a of Authorizing Individual: <br /> Date of Signature: � /3 <br /> -7--- <br /> Telephone Number: 5,"3 -• (11-1 <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/a Legal Department <br /> 2930 Wetmore Ave,Suite 10-C • <br /> Everett,WA 98201 <br />