Privacy and Insurance Authorization
Notice of Privacy Practices Written Acknowledgment Form Received
Infants, Children and Adolescents
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
have received a copy of University Pediatric Associates Notice of Privacy Practices.
Signature on File Insurance Authorization
I authorize payment of medical benefits to:
University Pediatric Associates for Medical Service(s) provided.
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