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|: FD-468 (Rev, 7-27-94) AUTHORITY TO RELEASE MEDICAL/MENTAL HEALTH INFORMATION | or other authorized representative of the Federal Bureau of Investigation bearing this release ; or a copy thereof, to obtain information available from my past or present medical records i maintained at/by Covemnvcr) men. #esPhitv¢ _, including those records relating to the treatment or care for drug abuse, alcoholism or mental health care including psychiatric Conditions, psychological care and professional counseling services. The release of these tl records ig necessary for employment or investigative purposes. If for employment purposes with another Government agency, the information obtained may be disseminated by the FBI to other Government agency or agencies. I request that the custodian of such records in each instance permit my records in connection therewith to be examined, copied or otherwise reviewed. I also realize that this release is subject to my revocation at any time except to the extent that action has been taken in reliance thereon. Absent such revocation, I understand b6 that this release is valid for one year from the date of signing. b7C Date: /AR /10 /3 2? Privacy Act Statement on Reverse Side PRI/DOJ