New Patient Record Release Authorization

For your convienence, print and complete the record release form to expedite new patient registration at your first visit.\r\n

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BEACH PEDIATRICS, PLLC 
\r\n 3227 Long Beach Rd, Ste 1
\r\n Oceanside, NY 11572
\r\n Phone: 516-897-5000 
\r\n Fax: 516-431-7519 
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\r\n RECORDS RELEASE AUTHORIZATION 
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\r\n TO: _________________________________________ 
\r\n _____________________________________________ 
\r\n _____________________________________________ 
\r\n _____________________________________________ 
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\r\n I HEREBY AUTHORIZE YOU TO RELEASE THE COMPLETE HISTORY AND MEDICAL RECORDS TO: 
\r\n BEACH PEDIATRICS, PLLC 
\r\n 3227 Long Beach Rd.  Ste 1
\r\n Oceanside, NY 11572 
\r\n Tel: 516-897-5000 
\r\n Fax: 516-431-7519 
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\r\n PATIENT NAME:______________________DOB:__________ 
\r\n ADDRESS:_________________________________________ 
\r\n _________________________________________________ 
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\r\n SIGNATURE:_________________________DATE:_________ 
\r\n WITNESS:___________________________DATE:_________\r\n

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