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AUTHORIZATION FOR USE/DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) Patient Name: MAN#:DOB: Last 4 SS#:Phone #:Address:All sections of this form must be filled out completely, or it will not be
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Mt. Ascutney Hospital and Health Center is a non-profit critical access hospital located in Windsor, Vermont.
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All non-profit hospitals are required to file Mt. Ascutney Hospital and Health Center.
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Information such as revenue, expenses, patient care statistics, and quality measures must be reported on Mt. Ascutney Hospital and Health Center.
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