**Medical Records Release Authorization**

I, Clifford Ray Hackett, hereby authorize the release of my medical records to any person or entity .

Patient Information:

• Clifford Ray Hackett

• general delivery Barrigada, GU 96913

• phone number 671-787-2345

• email address 3659745@gmail.com

I understand that this authorization covers the release of all medical records, including but not limited to, diagnoses, treatment plans, test results, and any other relevant medical information.

This authorization is valid FORVER