Medical Release Authorization Form

To:

Address:

City:

State:

Zip:

Phone Number

Fax Number

I hereby authorize and request you to release to:

AMHERST PEDIATRIC ASSOCIATES

25 HOPKINS ROAD

WILLIAMSVILLE, NEW YORK 14221

The complete medical records in your possession concerning my illness and/or treatment during the period

From:

To:

Patient’s Name:

Date of Birth:

Address:

Phone:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

Your information will be encrypted.