Central Jersey Pediatrics Infants, Children & Adolescents www.cjpediatrics.com

Patient Authorization For Release And Disclosure of Medical Records/ Protected Health Information (PHI)

Out going/ patient leaving our practice

Himanshu Patel, MD FAAP Central Jersey Pediatrics, PC 1553 Ruth Rd, Suite # 1 North Brunswick, NJ 08902

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

o After we receive a written request, we need seven-days to prepare your child�s medical record summary.

o You are expected to pick up record summery as we do not mail or fax it.

o As a courtesy to our patients, we will provide free medical record summary for the first time ONLY.

o We request that, you make appropriate copies of these records and keep with you, before you give them to any one else. If for some reason, you need the records again, you will be charged a $ 50.00 fee for it. We charge $ 50.00, to any insurance companies that require medical records.

o If you are unable to pick-up medical records in person, you can mange to get it by sending us prepaid Fed-Ex or UPS envelope.

o If you are changing physician it is not an emergency to acquire vaccination record of your child. We will not release any vaccination record on emergency basis.

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