Beverly Office
77 Herrick Street, Suite 201
Beverly, MA, 01915
Tel: 978-927-7246
Fax: 978-927-7249

Woburn Office
800 West Cummings Park, Suite 1200
Woburn, MA 01801
Tel: 781-927-7246
Fax: 781-305-4683

 

 

Authorization for Release of Medical Records - Woburn Location


* = denotes required field
 
 
 

Today's Date: 

 
 
 
 
 
 
 
 
 
 
 The specific information to be disclosed is:
   
 
 
 

I have carefully read and understand the above statements and do herein expressly and voluntarily consent to the disclosure of the above information about, or medical records of, my condition.

I hereby release the above-named keeper of the records from all liability that may arise from the release of these medical records.
 I understand that any person or organization to whom my records are disclosed may re-disclose this information if legally mandated.

I understand that this consent is subject to revocation at any time in writing unless action has already been taken in reliance upon it. This authorization will expire 1 (one) year from the date shown below unless otherwise stated here.

 
 Signature of patient, responsible person, or legal guardian (if minor):*

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