Edwin Krueger

 
 DocuSign Envelope ID: CD6AFC78-CF28-78AE-AA73-C1B65478D293 
 I understand that this revocation will not apply to information that has already been released in response to 
 this authorization. 
 I understand that when this information is used or disclosed pursuant to this authorization, it may be subject 
 to re-disclosure and may no longer be protected. 
 This Authorization is continuing in nature and remains effective until the conclusion of this claim / litigation 
 without the necessity for further authorization. 
 A copy of this Authorization shall be considered as effective as the original. 
 I, the undersigned, have read the above and authorize the staff of the above named facility to disclose such 
 information as herein contained. 
 DocuSigned by: 
 fairn 
 83DBEBA2C8F878C 
 Signature of Patient / Parent or Legal Guardian 
 2016/02/02 5:4 PM PDT 
 Relationship to Patient 
 Date Exp 2016/06/09
 This Authorization complies with 45 CFR 178.508 
 2
