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Get MA HIPAA-F-3 2003-2024

Ty #: Date of Birth: I authorize the Department of Mental Health (DMH) to release information to the person, facility or agency named below, either verbally or in writing, Name: Street: Attention: City/Town: Phone: State: Zip: DMH Contact Information: Name: Phone: Address: The person filling out this form must provide details as to date(s) of requested information. Please note that a request for release of psychotherapy notes cannot be combined with any other type of request. Specify in.

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