hosprals and the facilites Iisted at &..e birirling of tåis note; and bowl tan obtain access to and coutrol tisinforz&n Filistt Name Signa.ture of Patiezt or Personal Rapa-iset:ra-nve , Name of Panett or Persan7.1Represe.ntatve- Date , . • D escrip;d913 pf Personal R.,przsautrgte kl:hor:ty . • I