cover image: Northeastern Vermont Regional Hospital Mrn: ___________________ 1315 Hospital Drive Authorization to Disclose Protected Health Information Page 1 of 2 _________________ _________________ Signature of Patient/Legal Representative Date ______________________________ _________________________________ Print Name Relationship to Patient (If Signed by Legal Representative)

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Northeastern Vermont Regional Hospital Mrn: ___________________ 1315 Hospital Drive Authorization to Disclose Protected Health Information Page 1 of 2 _________________ _________________ Signature of Patient/Legal Representative Date ______________________________ _________________________________ Print Name Relationship to Patient (If Signed by Legal Representative)

2023

Pages
2
Published in
United States of America