I hereby authorize Berkeley Pediatric Medical Group 1650 Walnut St., Berkeley, CA 94709
to release medical records, including immunizations, concerning:
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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 and transfer my child’s protected health information to the above physician for the purpose of treatment. I understand that this authorization is in effect for one year from the date signed.
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