Central Jersey Pediatrics
Infants, Children & Adolescents
www.cjpediatrics.com
Patient Authorization For Release And Disclosure of Medical Records/
Protected Health Information (PHI)
In coming/New Patient

Dr.  
   
   
   
By signing this authorization, I authorize to release medical records / Protected health information (PHI) for
  Patient’s Name Date of birth
1
2
3
4
And forward them to:
Central Jersey Pediatrics
Somerset Professional Plaza
1527 Rt. 27 South, Suite # 1600
Somerset, NJ 08873
Ph. : 732-418-1700
Fax. : 732-249-9599
Signed: Print: Date
Relationship to Patient:

Somerset Professional Plaza, 1527 Rt 27 South, Suite 1600, Somerset, NJ 08873
Dayton Professional Ctr., 401 Ridge Rd. Suite 2, Dayton, NJ 08810
* Ph: 732-418-1700 * Fax: 732-249-9599