New Jersey Medical Records Release Form 2
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For Office Use Only:
M.R.#
P.A.#

SAINT BARNABAS
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:__________________________________