Medical Release Form - Outgoing

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Release of Information

For PAL to authorize release of confidential Protected Health Information, we must first receive a complete, signed release from a parent or legal guardian.

Authorization to Release Records

I hereby authorize Pediatric Associates of Lawrenceville to release pertinent medical information regarding the below named patient or patients. I understand that my permission to release information will include treatment of substance or other visas, HIV, psychiatric disorders, sexually transmitted diseases, etc., unless herein excepted.

Patients Information

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Pediatric Associates of Lawrenceville is hereby released from all legal responsibility for the release of records to the extent indicated and authorized herein.

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.

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