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ER University of Massachusetts Medical School Policy Umassmed  Form

ER University of Massachusetts Medical School Policy Umassmed Form

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Own records. TL-009320 12/2014. I may revoke this authorization at any time in writing. Any such revocation will not 1 change any action taken in reliance on the applicable law. Anxiety Depression Bipolar Disorder or any other mental disorder or condition I. Cancer Tumor Leukemia Hodgkin s Disease Polyps or Mole J. Alcohol or drug abuse or dependency Yes No A. Please print preferably in black ink. EMPLOYER USE MANDATORY DATA NEEDED In order to process this application the employer must complete...
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