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Ation and records created and/or maintained during your participation in the IRIS program. I hereby authorize the release, use and/or disclosure of my confidential health information as follows: 1. Participant Name Date of Birth Address Phone Number 2. Individual(s) / Agency / Organization Authorized to Release or Disclose the Information IRIS Consultant Agency (ICA) U.S. Bank Plaza, Suite 320, One South Pinckney Street, Madison WI 53703 OTHER (please specify by name) Address Phone Number 3.

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