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Description of omh form
Form OMH 11 9-10 State of New York OFFICE OF MENTAL HEALTH Patient s Name Last First M. I. C No.. AUTHORIZATION FOR RELEASE OF INFORMATION Sex. Date of Birth. Facility Name Unit/Ward/Residence No* This authorization must be completed by the patient or his/her personal representative to use/disclose protected health information in accordance with State and federal laws and regulations. Information may be released...
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