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Get Atlantic Cape Ob Gyn Fax Form

(609) 463-8100 829 Shore Road Somers Point, NJ 08244 (609) 927-3070 76 West Park Centre 76 W. Jimmie Leeds Road, Ste. 104 Galloway, NJ 08205 (609) 927-3070 Informed Authorization and Consent for the release of Medical Records I hereby authorize Atlantic Cape OB/GYN to: ( ) RELEASE ( ) OBTAIN the medical records of: whose date of birth is: and date of treatment was . ( ) RELEASE TO:.

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