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Get Confidential Authorization To Release

, (date of birth) (Student ID#) hereby authorize the release of medical information/records concerning me to the University of Houston Center for Students with DisABILITIES. I further authorize all health care professionals who have treated me to discuss the care and treatment they provided to me with the professional staff of the University of Houston Center for Students with DisABILITIES, and waive any physician/patient privilege or confidentiality protection to which I may be entitled.

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