Form 08-4228b - Authorization For Release Of Records

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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, employment, education records, and
records pertaining to litigation, judgments, suits 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 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 deemed 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 or 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, 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 a permit to practice as a direct-
entry midwife apprentice.
My Social Security
My Date of
Number is:
Birth is:
Home
Work
Telephone:
Telephone:
Signature:
Drivers License
Number:
Date:
08-4228b (Rev. 11/99)

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