Records Release Authorization

Please correct the errors described below.


I hereby authorize and request that you release The Immunization Records and Summary of Treatment During the period from (Start Date) to (End Date)
To: Pediatrics on Hudson 615 Broadway Hastings on Hudson, NY 10706
Phone: (914) 963 – 1663
Email: (preferred)
Fax: (914) 415 – 4918

For the following patient(s):

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