Authorization for use or disclosure of
Gardner CHC 175 Connors Street, Gardner, MA 01440 Leominster CHC 14 Manning Ave, Leominster, 01453 978-878-8100 www.chcfhc.org Authorization for Disclosure of Protected Health Information (PHI) This form is for the purpose of disclosures made through communication, access, or other uses of Protected Health ... ................
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