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My USC Lancaster

Authorization to Release/Disclose Health Information

*Required fields

Address, City, State, Zip

(000) 000-0000


I hereby authorize

of The University of South Carolina to use or disclose the following specific health information about myself to

I authorize the following information about myself to be released/disclosed: *

I understand that I may revoke this authorization at any time. If not previously revoked, this authorization will terminate on the following date, event or condition:

If no date or event is listed, this authorization will automatically terminate within 60 days from today.

The University of South Carolina, its employees, faculty, and officers are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

Please type your full name above as your electronic signature