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Www. abcdpediatrics. com 19238 Stonehue San Antonio TX 78258 P 210-494-2223 F 210-494-2631 2200 Roy Richard Dr. Schertz TX 78154 P 210-566-4777 2115 Stephens Place 900 New Braunfels TX 78130 P 830-214-6708 F 830-358-7711 121 Bulverde Crossing 100 Bulverde TX 78163 P 210-499-6400 Authorization to Release or Disclose Protected Health Information Patient s Name Date of Birth // Date of Request Address Day Time Ph Street city state zip code Please list where ABCD Pediatrics is to request medical...
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