Authorization for Access to Medical Information (For patients 18 years & older)

Please correct the errors described below.

Authorize the providers at:

Berkeley Pediatric Medical Group (BPMG)
1650 Walnut St., Berkeley, CA 94709

to release my health information to:

Records include a summary of care, immunization records, growth charts and pertinent medical information specific to your child.

By signing this authorization, I give permission for BPMG to release protected health information to the above, including verbal communication

By signing this authorization, I give permission for BPMG to release protected health information to the above, including verbal communication

I may revoke this authorization in writing, at any time

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

Your information will be encrypted.

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