Authorization for Release of Medical Record Information
Above listed patient authorizes the following healthcare facility to make record disclosure:
Bellevue Pediatrics 1230 Parkway Ave. Suite 303 Ewing, NJ. 08628 ph: 609-989-9801 fx: 888-736-4821
Please List the Name, Address, E-mail, Phone, and Fax # of whom we are sending records.
This will be used as your official signature