I acknowledge that the above requested records will NOT be released until any existing balance has been cleared from my family’s account.
I understand that this entire form must be completed before any records can be released.
I acknowledge that this authorization is valid for a period of 6 months or until expressly revoked by me. I understand that I may withdraw this authorization by submitting a written, dated request, and that such revocation does not affect action that has already been taken based on this authorization.
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