Privacy and Insurance Authorization

Notice of Privacy Practices Written Acknowledgment Form Received

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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.

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I authorize payment of medical benefits to: University Pediatric Associates for Medical Service(s) provided.

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