Newborn Record Release

Saugatuck Pediatrics LLC

191 Post Road West, Suite 201

phone (203) 793-4747

fax (877) 809-0848

www.saugatuckpeds.com
Authorization to Release/Transfer Medical Records

I hereby authorize the release of my child/children's medical records to:

Saugatuck Pediatrics LLC
Child's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the date notified except to the extent action has already been taken in reliance upon it. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by Federal privacy regulations.
Parent/Guardian*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
By checking this box you agree to receive text messages from Saugatuck Pediatrics, you can reply stop to opt-out anytime.
Signature of Parent/Guardian*

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