Goodman Pediatrics

Info Release

Please correct the errors described below.

The undersigned hereby authorizes and requests: Goodman Pediatrics, LLP 500 Helendale Rd, Suite 200 Rochester, NY 14609 Phone: (585)473-7028 Fax: (585)473-0051 To release information contained in patient’s medical records for the purpose of documentation to:

The authorization shall expire twelve (12) months from the date signed.

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