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Medical Release (english)

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
* Required field