RELEASE BY WHOM I authorize Stanford University Occupational Health Center, located at 480 Oak Rd., Stanford, CA 94305-8007 to release the medical information specified above to _____________

I understand that: (a) the authorization is subject to revocation at any time, by written notification only to the holder of the medical information specified above, except to the extent that the holder

of the medical information has already disclosed the information; (b) the information disclosed may be subject to redisclosure by the recipient and may no longer be protected; (c) I may refuse to

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