• Authorization for Release of Information

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  • I understand that I may revoke this authorization at any time in writing, and it will be effective on the date of organization notification except to the extent action has already been taken in reliance upon it.  I understand that, unless revoked, this authorization will be valid for one year after signature.  I understand that information to be released or obtained may include mental health, medical, substance abuse or HIV/AIDS-related information.

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    Pick a Date
  • Just Breathe Connecticut LLC     4 West Road     PO Box 566     Ellington CT 06029     

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