MEDICAL RECORD RELEASE AUTHORIZATION (TO US)

Union Mill Pediatrics, P.C.

Date:

To:

Address:

I authorize the release of my child(ren)’s medical records to:
Union Mill Pediatrics, P.C.:
Dr. Maura Eriksson
Dr. Wayne Eriksson
Dr. Shoshana Killian
Dr. Pooja Dhananjayan

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Parent or Legal Guardian

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