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 · PO Box 2800 Portland OR 97208-2800 800.368.2859 Tel 800.378.6053 Fax 1 AUTHORIZE THESE PERSONS having any records or knowledge ofme or my health: Any physician, medical practitioner

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Page 1:  · PO Box 2800 Portland OR 97208-2800 800.368.2859 Tel 800.378.6053 Fax 1 AUTHORIZE THESE PERSONS having any records or knowledge ofme or my health: Any physician, medical practitioner
Page 2:  · PO Box 2800 Portland OR 97208-2800 800.368.2859 Tel 800.378.6053 Fax 1 AUTHORIZE THESE PERSONS having any records or knowledge ofme or my health: Any physician, medical practitioner
Page 3:  · PO Box 2800 Portland OR 97208-2800 800.368.2859 Tel 800.378.6053 Fax 1 AUTHORIZE THESE PERSONS having any records or knowledge ofme or my health: Any physician, medical practitioner
Page 4:  · PO Box 2800 Portland OR 97208-2800 800.368.2859 Tel 800.378.6053 Fax 1 AUTHORIZE THESE PERSONS having any records or knowledge ofme or my health: Any physician, medical practitioner
Page 5:  · PO Box 2800 Portland OR 97208-2800 800.368.2859 Tel 800.378.6053 Fax 1 AUTHORIZE THESE PERSONS having any records or knowledge ofme or my health: Any physician, medical practitioner

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