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Get CT Hartford HealthCare 571559 2012-2024

ATION TO DISCLOSE/OBTAIN HEALTH INFORMATION Subject to the statements printed on the back, I, the undersigned patient or legal representative, hereby authorize the use and disclosure of health information including, if applicable, information relating to the diagnosis or treatment of mental illness, drug and/or alcohol abuse and HIV related information. Patient Name: Date of Birth: FILL OUT FOR HARTFORD HOSPITAL TO DISCLOSE.

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