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  • AUTHORIZATION TO REQUEST OR RELEASE HEALTH INFORMATION

  • Saugatuck Pediatrics LLC

    191 Post Road West, Suite 201

    Westport, CT 06880

    www.saugatuckpeds.com

    Phone (203) 793-4747

    Fax (877) 809-0848

  • I,      the parent or guardian of the following children (or self if aged 18+ years): Child 1:      DOB:   Pick a Date  Child 2:      DOB:   Pick a Date   Child 3:      DOB:   Pick a Date   Child 4:      DOB:   Pick a Date   Child 5:      DOB:   Pick a Date


  • Hereby authorize Saugatuck Pediatrics LLC to: 

    Request Records FROM:   Physician and/or Practice:    

    Release Records TO: Physician and/or Practice:   

    Release Records to Self:

  •  -

  • This authorization will expire on:   Pick a Date*   
    If I fail to specify a date, this authorization will expire in 6 months from he date it was signed.
    I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization in writing, the revocation will not apply to information that has already been released.


    ***   
    Signature/Phone Number of Parent/Guardian (or patient if aged 18+ years)

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