DeptFord Medical Center

I authorize the release of my medical records by the organization or Physician listed below.

These records are to be sent to DEPTFORD MEDICAL CENTER - FAX NUMBER: 856-848-8038

I understand this authorization will expire, without my revocation, one year from this date of signing, or if I am a minor on the date; I become an adult according to the state law. I understand that I may revoke this authorization or to my insurance company. I understand that any discourse and the information may not be protected by the federal Confidentiality rules. I accept full financial responsibility of any copying or shipping fees and any applicable sales tax that may be charged.