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INSTITUTE OF NEUROLOGY 200 South Orange Avenue, Suite 165 Livingston, NJ 07039 AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION TO Institute of Neurology:PATIENT NAME:___ D.O.B.:___ S.S.#:___
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The bhmg-medical-record-form-and-disclose-authorizationpdf is a document used to authorize the release of an individual's medical records in accordance with privacy regulations.
Patients or their legal representatives are required to file the bhmg-medical-record-form-and-disclose-authorizationpdf when they want to allow healthcare providers to share their medical information.
To fill out the form, individuals need to provide their personal information, specify what records they request, and sign the form to authorize the release.
The purpose of the form is to ensure that patients consent to the sharing of their medical records, thereby complying with healthcare privacy laws.
The form must include the patient's name, date of birth, the specific medical records requested, the purpose of the disclosure, and the signature of the individual or their representative.
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