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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