Authorization for Release of Medical Information

Please correct the errors described below.

hereby authorize:

University Pediatric Associates, P.A.

To release medical records on:

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Release To:

**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.

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

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