Free Medical Release Form 32Free Medical Release Form 32
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SAINTBARNABAS
For Office Use Only:
M.R.#
P.A.#

HEALTH CARE SYSTEM
Clara Maass Medical Center
1 Clara Maass Drive Belleville, NJ 07109

AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION
PATIENT NAME:_____________________________________________________________________________
D.O.B.:_____________
ADDRESS:___________________________________________________________________________________
TELEPHONE:_________________________________________________________________________________
I hereby authorize The Health Information staff of Clara Maass Medical Center of Belleville, NJ to disclose my
health information to:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The information to be disclosed to and used by the above is for the following
purpose:________________________________________________________