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AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION Child and Adolescent Health Specialists, PC 223 Chief Justice Cushing Hwy, Ste 201 Cosset, MA 02025 Patient Name Date of BirthTelephone #Street
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The MR Release Form is a document used to authorize the release of certain medical records and information for individuals, often used in legal or insurance contexts.
Individuals or entities that need to access or share medical information, such as healthcare providers, insurance companies, or legal representatives, are required to file the MR Release Form.
To fill out the MR Release Form, you need to provide personal information, specify the records to be released, indicate the purpose of the release, and sign the document to grant authorization.
The purpose of the MR Release Form is to ensure that an individual's medical information is disclosed only with their consent, thereby protecting patient confidentiality.
The MR Release Form must include the individual's name, date of birth, specific medical records requested, the purpose for the release, and the recipient's information.
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