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Authorization of Release of Records

  • MM slash DD slash YYYY
  • To release information in my medical record to:
    Amanda N. Hale, O.D.
    457 Dalton Avenue
    Pittsfield, MA 01201
    Phone: 413-442-9421
    Fax: 413-443-3115
  • Name/Address/Fax #
  • MM slash DD slash YYYY
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