Beach Pediatrics is a division of Allied Pediatrics of New York
 
 
OFFICE HOURS
 
 
ABOUT OUR PHYSICIANS
 
 
HIPPA 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
 
 
SWINE INFLUENZA UPDATE
 
 
SWINE FLU (H1N1) VACCINE AVAILABILITY
H1N1 vaccine availability
 
 
NYDOH SWINE FLU (H1N1) UPDATE
LATEST H1N1 VACCINE UPDATE 10/31/09
 
 
Allied Pediatrics
Learn about Allied Pediatrics and our after hours care here
 
 
PATIENT SURVEY
 
 

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:_________

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