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Authorization shall be considered as valid as the original. This information is being requested for the purpose of evaluating a claim made by me or on my behalf, and/or for preparing for, conducting, and/or participating in any mediation, arbitration, hearing, trial, or other proceeding associated with my claim. This Authorization shall be valid for one year from the date signed. This is not a release of claims for damages. I further understand that I am entitled to a copy of this Authorization.

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