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SpringfieldCollegeHealthCenter 263AldenStreet Springfield,Massachusetts01109 (413)7483175 (413)7483444(fax) AUTHORIZATIONTORELEASEMEDICALINFORMATION Name: Dateofbirth: SSN: ID#: Phone: PermissionisherebygivenforSpringfieldCollegeHealthServicestorelease/requestthefollowinginformationfromthe
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