Record Release Form "*" indicates required fields Authorization for Release of InformationOrganization Name* Is authorized to release information or records about:Last Name* First Name* Middle Initial* Address City State Zip Code Phone Number*Specific information to be used or disclosed: Person or organization authorized to receive information or records:Name* Phone Number*Address City State Zip Code SignatureCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
