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Get Northeast Guidance Center Authorization To Release Protected Health Information 2003-2024

City/State/Zip: D.O.B. (mm/dd/yy): Soc. Sec.#: Request Case# Date: I, the below named person, authorized the release of the following protected health information (which may include storage or fax transmission of records), including alcohol and drug abuse records protected under the regulations in Code 42 of Federal Regulations, Part 2, if any; psychological services records, if any; and social services records; if any; including communications made by me to a social worker or psychologi.

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