MEDICAL RECORDS RELEASE FORM

To: Medical Record Department

Please send the requested documents to:
Passaic Pediatrics, PA
298 Passaic St Passaic, NJ 07055
200 Gregory Ave 2nd Floor Passaic, NJ 07055
Tel: 973-249-8100
Fax: 973-249-8110
Email: staff@passaicpediatrics.com

Permission is hereby granted to Passaic Pediatrics for release of information from the medical records of:

Patient's Name:*

D.O.B:*

MM/DD/YYYY

Email*

example@example.com

(Street Address)*

(City, State, Zip Code) *

Parent / Legal Guardian’s Name*

Date*

MM/DD/YYYY

Parent / Legal Guardian’s Signature*

*****CONFIDENTIALITY NOTICE*****
The documents accompanying this telecopy transmission contain confidential information belongings to the Sender that is legally privileged. The information is intended only for the use of the individual or entity name above. The authorized recipient of this information is prohibited from disclosing this information to any other party and is required to destroy the information after its stated need has been fulfilled, unless otherwise required by state law. If you are not intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you have received this telecopy in error, please notify the sender immediately to arrange for return of these documents.