Please correct the errors described below.

Including HIV, AIDS, & ADD/ADHD, psychiatric illness and related information

to release the following information from the medical records of:

Information to be released:

Information is to be released to:

Mt. Airy Pediatrics, PC
6673 Germantown Ave.
Philadelphia PA 19119-2252
Tel# 215-247-2996/Fax# 215-247-7504

5. I understand this consent can be revoked at any time except to the extent that disclosure made in good faith has already occurred in reliance on this consent and is valid for one year from date of signing. It can be revoked at any time.

6. The facility, its employees and officers and attending physicians are released from legal responsibility or liability for the release of the above information to the extent indicated and authorized herein.

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