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Get RiverBend Authorization for Use or Disclosure of Medical Record Information (Formerly 204-RG) 2013

Ord #: 395 Southampton Road Westfield, MA 01085 70 Post Office Park Wilbraham, MA 01095 Patient Information Patient Full Name: Date of Birth: Patient Address: Home Phone: City: State Release of Information Zip: Work Phone: I hereby Authorize RiverBend Medical Group to: Discuss Medical Record Information With: Mail Copies of my Medical Information to: To obtain my individually identifiable health records from: Hold for Patient Pick-up Name/Facility: Attention: Address: Phone: .

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