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