AUTHORIZATION TO RELEASE INFORMATION

TO WHOM IT MAY CONCERN:

     YOU ARE HEREBY AUTHORIZED TO release and/or disclose to my attorneys, WINER MEHEULA & DEVENS LLP, information, data, medical records, billings, psychiatric records and any and all other matters which they may request of you.

     A copy of this release shall have the full force and effect of the executed original.

     Dated: , Hawaii .

Your Full Name:

Your E-mail Address:

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