AUTHORIZATION FOR RELEASE OF MEDICAL
RECORDS
To Jennifer Williams M.D.,
You are authorized to release to Smith, Jones, and
Johnson, any and all medical records related to treatment that I may have
received during August, 1999.
A photocopy of this authorization shall have the
same force and effect as an original.
All prior authorizations are
canceled.
Dated: ___________________
__________________________________
Robbie Winns
Social Security Number: __________________
Date of birth:
___________________________
