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Get Ma Fenway Health Authorization For Disclosure Of Protected Health Information 2010-2024

SOCIAL SECURITY NUMBER DATE OF BIRTH MAIDEN NAME I HEREBY AUTHORIZE: NAME, TITLE ORGANIZATIONS/DEPARTMENT, ADDRESS, PHONE NUMBER To release information from my health record to: NAME, TITLE ORGANIZATIONS/DEPARTMENT, ADDRESS, PHONE NUMBER This authorization covers the following records: q All records q My record for treatment of (please specify diagnosis or symptom.) q My record for treatment received during the following time period.

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