Directory Results for AUTHORIZATION FOR RELEASE OF INATION Patient Name: Date of Birth: Address: (street) (city) (state) (zipcode) Phone Number: I authorize Kennedy Health the use or disclosure of the above named individual 's health information as described to AUTHORIZATION FOR RELEASE OF INATION PATIENT NAME: DOB: I, , hereby authorized To obtain ( ) release ( ) the following specific information regarding treatment Dates: INFORMATION TO BE RELEASED TO: Individual or organization: Address: I