Pediatric Specialists

Authorization for Release of Medical Records and Information

Please correct the errors described below.

Please allow up to fifteen (15) business days for completion.

Medical records will be sent USPS Certified Mail (signature required) to:

authorize Pediatric Specialists of Foxboro and Wrentham to release my (my child's) entire medical record.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

(Request only valid for 6 months from today)

Your information will be encrypted.