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For Office Use Only: M.R.# P.A.# BARNABAS HEALTH Clara Maass Medical Center 1 Clara Maass Drive Belleville, NJ 07109 AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION PATIENT NAME: D.O.B.: ADDRESS:.

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Complete Barnabas Health Authorization To Disclose Protected Health Information in a few clicks by using the instructions listed below:

  1. Choose the template you want in the collection of legal forms.
  2. Click the Get form key to open it and move to editing.
  3. Complete all the necessary fields (they will be yellow-colored).
  4. The Signature Wizard will allow you to insert your electronic signature right after you have finished imputing data.
  5. Insert the date.
  6. Look through the entire document to make certain you have filled in all the information and no corrections are needed.
  7. Press Done and download the filled out document to the device.

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