7405 Shallowford Road, Ste 420
Chattanooga, TN 37421
Phone: 423-855-8522
Fax: 423-855-8533
A copy of this authorization may be utilized with the same effectiveness as an original.
Expiration or revocation of authorization: I understand that I may revoke this authorization at any time and that, unless an earlier date is specified, it will automatically expire 12 months after the date below.