Authorization For Release Of Information Form - State Of Alaska 2004 Page 2

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*REVOCATION SECTION*
I do hereby request that this authorization to release the information of: ________________________________________
(Printed Name of Client)
described on the reverse side of this form, be rescinded, effective _______________________. I understand that any
(Date)
action taken on this authorization prior to the rescinded date is legal and binding.
___________________________________________________
__________________________________________________
Signature of Client or Personal Representative
Date
(Or Witness if signature is by mark)
___________________________________________________
__________________________________________________
Printed Name of Personal Representative or Witness
Description of Personal Representative’s Authority
___________________________________________________
Signature of Staff
*
This Revocation Section must appear on the reverse side of DHSS Authorization for Release of Information 06-5870 (03/03) and is
invalid if used separately. If a separate form is required, use DHSS Revocation of Authorization for Release of Information 06-5872
(03/03). If this revocation section has been completed and signed, please note the date of the revocation on the reverse side of this
form in the space provided.
06-5870 (Rev. 01/12/04)
A PHOTOCOPY OF THIS AUTHORIZATION IS AS VALID AS THE ORIGINAL
Page 2 of 2
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