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I hereby authorize the release and disclosure of the following clinical and/or therapeutic records for the following purpose(s):

Revocation/Expiration: This Release of Information is subject to revocation by the under-signed at any time except to the extent that information has already been disclosed based on authorization contained herein. Unless further limited by a date stated here (below) this Release of Information will automatically expire after a period of 180 days from the date signed. I have the right to receive a copy of this Release of Information upon my request.