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East Haven Pediatrics, PC 300 Main Street, East Haven, CT 06512 (203) 4698882 Fax (203) 4679973 AUTHORIZATION TO RELEASE AND/OR EXCHANGE INFORMATION Today's Date Birth date: Street Address: City:
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How to fill out East Haven Pediatrics PC:

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Start by gathering all necessary information such as personal details, medical history, and insurance information.
02
Fill in the patient's personal details accurately, including their full name, date of birth, address, and contact information.
03
Provide the patient's medical history, including any previous illnesses, surgeries, allergies, or ongoing medications. It is important to be thorough and honest in this section.
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If applicable, fill out the insurance information section. This includes the patient's insurance provider, policy number, and any additional details required by the clinic.
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Answer any specific questions or sections on the form related to the patient's reason for visit or any specific concerns they may have.
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Double-check the form for accuracy and completeness before submitting it to East Haven Pediatrics PC.

Who needs East Haven Pediatrics PC:

01
Families with children: East Haven Pediatrics PC is a pediatric care provider, meaning they specialize in the medical needs of infants, children, and adolescents. Therefore, families with children who require medical care or regular check-ups would benefit from their services.
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Residents of East Haven: As the name suggests, East Haven Pediatrics PC serves the community of East Haven. Therefore, individuals residing in East Haven or nearby areas may find it convenient to seek pediatric care from this facility.
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Parents seeking specialized care for their child: East Haven Pediatrics PC offers a range of specialized services such as allergy testing, developmental screenings, and sports physicals. Therefore, parents who require these specific services for their child could benefit from seeking care at this facility.
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East Haven Pediatrics PC is a medical practice in East Haven specializing in pediatric care.
The owners or operators of East Haven Pediatrics PC are required to file.
East Haven Pediatrics PC can be filled out by providing all relevant financial and operational information of the practice.
The purpose of East Haven Pediatrics PC is to report financial and operational information of the medical practice.
Information such as revenue, expenses, patient volume, and services provided must be reported on East Haven Pediatrics PC.
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