Social Security Number, no dashes, just the last 4 numbers please

patient hereby requests and authorize

To release copies of my complete medical records and any and all orther information regarding my diagnosis testing and / or treatment that is maintained by licensee for whom the complaint is files against to WEST VIRGINA BOARD OF OPTOMETRY, 172 Summers Street, Charleston, WV 25301.

I understand that this authorization may be revoked at any time, except to the extent action has been taken prior to revocation.  This consent will expire in sixy (60) days after the date signed below or sonner at my election.  I acknowledge that I have read and understand theis authoriziation as it applies to me.

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