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NEW PATIENT RECORD RELEASE AUTHORIZATION

For your convienence, print and complete the record release form to expedite new patient registration at your first visit.

BEACH PEDIATRICS, PLLC
312 Long Beach Rd.
Island Park, NY 11558
Tel: 516-897-5000
Fax: 516-431-7519


RECORDS RELEASE AUTHORIZATION



TO: _________________________________________
_____________________________________________
_____________________________________________
_____________________________________________

I HEREBY AUTHORIZE YOU TO RELEASE THE COMPLETE HISTORY AND MEDICAL RECORDS TO:
BEACH PEDIATRICS, PLLC
312 Long Beach Rd.
Island Park, NY 11558
Tel: 516-897-5000
Fax: 516-431-7519


PATIENT NAME:______________________DOB:__________
ADDRESS:_________________________________________
_________________________________________________


SIGNATURE:_________________________DATE:_________
WITNESS:___________________________DATE:_________

Other pages:

Beach Pediatrics is a division of Allied Pediatrics of New York

OFFICE HOURS

ABOUT OUR PHYSICIANS

Allied Pediatrics
Learn about Allied Pediatrics and our after hours care here
HIPAA STATEMENT

NEW PATIENT REGISTRATION FORM

NEW PATIENT OFFICE POLICY SIGNATURE FORM

NEW PATIENT RECORD RELEASE AUTHORIZATION

EDUCATION - Colic, Constipation, Bottle/Breast Feeding

HELPFUL LINKS / Vaccines, Acd. of Peds, Car Seat Guidelines, Centers for Disease Control & Prevention

NEWS LETTERS

PATIENT SURVEY

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