I hereby authorize:
to release medical records, including immunizations, concerning:
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To: Berkeley Pediatric Medical Group
1650 Walnut Street, Berkeley, CA 94709
Phone: (510) 848-2566
Fax: (510) 848-2503
By signing this authorization. I give permission to release and transfer my child’s protected health information to the above requesting doctor for the purpose of treatment. I understand that this authorization is in effect for one year from the date signed.
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