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 
3227 Long Beach Rd, Ste 1
Oceanside, NY 11572
Phone: 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 
3227 Long Beach Rd.  Ste 1
Oceanside, NY 11572 
Tel: 516-897-5000 
Fax: 516-431-7519 

PATIENT NAME:______________________DOB:__________ 
ADDRESS:_________________________________________ 
_________________________________________________ 

SIGNATURE:_________________________DATE:_________ 
WITNESS:___________________________DATE:_________