Authorization for Release of Medical Information

hereby authorize:

University Pediatric Associates, P.A.

Our Locations:

317 Cleveland Avenue, Suite 204, Highland Park, NJ 08904. Phone: (732) 249-8999 Fax: (732) 249-7827

D-1 Brier Hill Court, East Brunswick, NJ 08816. Phone: (732) 238-3310 Fax: (732) 613-6051

To release medical records on:

Patient Name

Birth Date

Add more information

Release To:

Name(s):

Address:

City:

State:

Zip:

Current Phone Number:

**If moving please provide change of address and current phone number

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

Signature:

Date:

Why are you leaving:

****Any current insurance balance not covered by insurance will become the responsibility of the insured.

Your information will be encrypted.