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Authorization for Release of Patient Information

This document authorizes Eric Stelnicki, MD PA to discuss any privileged or confidential information, and to provide full and complete patient reports and records justifying the course of treatment including but not limited to: Patient histories, x-rays, examination and test results, reports or information prepared by other persons that may be in possession to my referring physician or any other medical personnel who may be involved in my care.

After submitting the request for the records please send us a copy of your driver's license by fax to 954-986-6846 so we can confirm your identity and relationship to the patient. Please note if we forward the records to another physician the records are free if they are for personal use you would have to pay $1 per page prior to the records being released. If you have any further questions regarding medical records please call the office at 954-983-1899 x 105.

***we can only mail or fax medical records***

Patient's Name:
Date of Birth:
Release records to:
Insurance Patient/Guardian Print:

I accept and understand that by putting my name in the signature box I give permission for that to be used as an electronic signature.

Patient/Guardian Signature:


  • Joe DiMaggio Children's Hospital
  • American Association of Plastic Surgeons

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