AUTHORIZATION TO DISCLOSE CONFIDENTIAL

MEDICAL INFORMATION

I authorize Dr. ________________________ to disclose complete information to

_____________________________ concerning __________ (his or her) medical

findings and treatment of me from on or about ____________________ (date)

until the date of the conclusion of the treatment. I expressly waive, on behalf of myself

and any persons who may have an interest in the matter, all provisions of law relating

to the disclosure of information acquired through examination or treatment.

Dated this _________ day of _____________, 20___.

________________________________

Employee Signature