Christopher Lam, MD 1930 Marlton Pile East Suite A-9 Cherry Hill, NJ 08003 Phone: 856-448-4560 AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION Patient’s Name: Date of Birth: Previous Name: I request and authorize to release any records or information regarding drug, alcohol, or mental health treatment of the patient named above to: Name: South Jersey Psychopharmacology Address: 1930 Marlton Pike East suite A-9 City: Cherry Hill State: NJ Zip Code: 08003 X Yes No I authorize South Jersey Psychopharmacology to release any records regarding drug, alcohol, or mental health treatment to the person(s) listed above. Patient Signature: Date Signed: Parent Signature: Date Signed: THIS AUTHORIZATION EXPIRES ___ DAYS IT IS SIGNED (one year if blank)
Christopher Lam, MD 1930 Marlton Pile East Suite A-9 Cherry Hill, NJ 08003 Phone: 856-448-4560 AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION Patient’s Name: Date of Birth: Previous Name: I request and authorize to release any records or information regarding drug, alcohol, or mental health treatment of the patient named above to: Name: South Jersey Psychopharmacology Address: 1930 Marlton Pike East suite A-9 City: Cherry Hill State: NJ Zip Code: 08003 X Yes No I authorize South Jersey Psychopharmacology to release any records regarding drug, alcohol, or mental health treatment to the person(s) listed above. Patient Signature: Date Signed: Parent Signature: Date Signed: THIS AUTHORIZATION EXPIRES ___ DAYS IT IS SIGNED (one year if blank)
release_doc.docx