RELEASE OF INFORMATION FORM

The form below is our Release of Information Form.

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Step 1 of 2
Gerald Lewis Inc.
3000 Murvihill Rd.
Valparaiso, IN 46383
AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
1. INDIVIDUAL PATIENT (OR PERSONAL REPRESENTATIVE) CONFIRMING THE AUTHORIZATION
(Sr., Jr., etc)
2. THE USE AND/OR DISCLOSURE AUTHORIZED