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Mit Authorization Form
ZIP Provider phone number to disclose a copy of the following portion(s) of my medical record to MIT Medical: □ □ □ □ □ □ □ □ □ Admission notes: EKGs/echo: Pathology reports: Consult report: □ □ □ □ Progress notes: Immunizations: X-ray reports: Emergency service report: Office notes: Lab reports: Hist & Phys: □ □ □ Stress tests: □ □ Abortion Mammogram: Op report: Entire medical record Other: 3. RECIPIENT AUTHORIZATION To the attention of □ at MIT Medical (check...Show details
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