Massachusetts Medical Records Release Form 4Massachusetts Medical Records Release Form 4
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Medical Records
Release Form
This request is directed to the following physician:
q Dr. Steven Barrett
q Dr. Gregory Bazylewicz
q Dr. Harlow LaBarge
195 School Street w  Manchester, MA 01944 w Phones 978-526-4311, 978-526-7507 w Fax 978-525-2342
q Dr. William Medwid
q Dr. Hugh Taylor
q Dr. Andrew Ting
15 Railroad Avenue w Hamilton, MA 01982 w Phone 978-468-7381 w Fax 978-468-6020
q Dr. Mark Allara
q Dr. Phillip Burrer
q Dr. Michael Yoon
q Dr. Meghan Tramontozzi
147 South Main Street w Middleton, MA 01949 w Phone 978-774-2555 w Fax 978-774-8715

Patient Information:
Last name: _________________________________ First name: _________________________________ Middle initial: ___________
Street or PO Box_______________________________________________________________________________________________
City: ____________________________________________________State: __________________ Zip:________________________
Telephone: ___________________________________ Date of birth: ______________________