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AUTHORIZATION TO RELEASE PROFESSIONAL INFORMATION
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  The above agency and {Company Name} to exchange information with each other on an ongoing basis for the duration of the terms of this release. This release needs to be renewed annually unless terminated at an earlier time by written notification.
 

Any information released or exchanged may not be disclosed to any other agency except those required by law. The following information is included in this release:

 

   
   
   
   
   
  

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  This consent automatically expires 30 days after termination of services

 

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I accept that this is the legal representation of my signature.