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About
Bronx Treatment Center
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AUTHORIZATION FOR RELEASE OF
HEALTH INFORMATION PURSUANT TO HIPAA
Submit HIPAA Authorization Form
Patient's First Name
(Required)
Phone#
(Required)
Email
(Required)
Date of Birth
(Required)
Scan Copy of HIPPA Authorization Form with Duly Signed
(Required)
Accepted file types: pdf, Max. file size: 4 MB.
Submit