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AUTHORIZATION FOR MEDICAL RECORDS To Whom It May Concern: hereby authorize the release of all medical documentation and other information which may be in the possession any insurer, physician, surgeon, hospital, ambulance service or nurse, to any representative of McNeil & Company, Inc., on behalf of the Cortland County Self Insurance Fund, regarding my injuries, medical history, and physical & mental condition both prior to and subsequent to the date of this authorization, regardless of lapsed time. Upon presentation of this authorization (or a photocopy), you are authorized to release a copy of these records to any of representative of McNeil & Company, Inc., on behalf of Cortland County Self Insurance Fund, I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal law. The purpose of the disclosure is at my request and this Medical Authorization shall be deemed to comply with the requirements of the Health Portability and Accountability Act (45 CFR 164.508). This Medical Authorization shall expire upon final resolution of my pending claim with McNeil & Company, Inc., on behalf of Cortland County Self Insurance Fund, I understand that I may revoke this Medical Authorization at any time by sending written notice to the medical providers and to McNeil & Company, Inc. Date of (Claimant) (Witness) (Claimant Signature) (Witness Signature)