Form 08-601b - Authorization For Release Of Records

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NAT
State of Alaska
Department of Community and Economic Development
Division of Occupational Licensing
Naturopath Section
P.O. Box 110806, Juneau, Alaska 99811-0806
(907) 465-2695
E-mail: license@dced.state.ak.us
AUTHORIZATION FOR RELEASE OF RECORDS
To Whom It May Concern:
I,
residing at
authorize the Alaska Division of Occupational Licensing and its investigators to examine my medical, dental, employment,
and education records, and any records pertaining to litigation, suits, judgments and/or settlements, and any law
enforcement records pertaining to me and discuss them with persons having possession of them. I also expressly permit
and authorize the release of any and all such records pertaining to me to the Alaska Division of Occupational Licensing
and its investigators.
I authorize the Division to discuss my records with persons or organizations which are considered appropriate by the
Division in connection with an official investigation, and to provide copies of my records to those persons or organizations
considered appropriate by the Division.
This release also applies to any documents or records which contain information pertaining to psychiatric, drug or alcohol
evaluation, diagnosis, or treatment received by me and which were prepared or made in conjunction with, or under the
authority of guidance of any local, state, or federal law which relates to psychiatric, drug or alcohol evaluation, diagnosis
or treatment.
I request that upon presentation of this release, or a certified true copy of it, that you provide copies of those records to
the Division and/or its investigators, and/or representatives of the Office of the Attorney General of the State of Alaska.
This authorization is given expressly in connection with my application for initial issuance of a license as a naturopath.
This authorization expires one year from the date of my signature below.
Signature:
Date:
Social Security Number:
Date of Birth:
Home Telephone:
Work Telephone:
08-601b (Rev. 1/00)
(5)

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