• AUTHORIZATION FOR RELEASE OFMEDICAL INFORMATION

  • I, , hereby authorize the release of medical information to:

    Maeville Pediatrics
    8540 Broadway Street, Suite#205
    Pearland TX 77584
    Phone: (832) 582-7146
    Fax: (832) 962-8154

    Doctor/Hospital from whom records are being released (this is usually your previous pediatrician’s office or your child’s birth hospital):
       

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