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O. Box 20070 Cranston RI 02920-0941 Telephone 401 462-8420 Fax 401-462-8466 TTY Via RI Relay 711 AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Please provide this to your Qualified Healthcare Provider or Facility. Do not send to TDI. Doctor s Name Doctor s Address Patient s Date of Birth Last 4 Digits of Patient s S.S. Patient s Name Patient s Address You are hereby authorized to furnish and release to the Rhode Island Department of Labor Trai.

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