RECORD RELEASE

Kintiroglou Pediatrics
1500 Pleasant Valley Way, Suite 301 West Orange, NJ 07052 973-243-0002
 
Date:
To:   KINTIROGLOU PEDIATRICS
 
I hereby authorize you to release to





 
any information including the diagnosis and records of any treatment or examination rendered to [patient &/or patients’ name(s).]
during the period from to  
 
By signing this release I hereby acknowledge my understanding that we are nolonger part ofKintiroglou Pediatrics, will only receive emergency care for 30 days from date of request, and that we cannot be accepted back into the practice without the approval of the office manager and/or physicans. The charge for obtaining records is $1/page, with a maximum of $25.00 plus postage fees. In addition, records must be picked up in our office or mailed directly to you. Payment in person or via phone must be paid in full before the release of records.
Reason for leaving practice?
 
Please provide a cell number and email address to contact you when the records are complete.

Email Address

Cell Number
 
___________________________________
PATIENT/GUARDIANS SIGNATURE
 

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