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) 476 – 1663 Fax: (914) 476 – 5373 For the following patient(s):

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