New Jersey Medical Records Release Form 1
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DEPARTMENT OF HEALTH AND SENIOR SERVICES
CONSUMER AND ENVIRONMENTAL HEALTH SERVICES
PO BOX 369
TRENTON, N.J. 08625-0369
www.nj.gov/health

JON S. CORZINE
Governor

FRED M. JACOBS, M.D., J.D.
Commissioner

MEDICAL RECORDS RELEASE FORM
Patient’s Name: ____________________________________
Address:

____________________________________
____________________________________

Date of Birth:

____________________________________

I hereby authorize

___________________________________
Physician’s name
___________________________________
Physician’s phone number
___________________________________
Physician’s fax number (if known)
___________________________________
Physician’s address (if known)

to release my medical records via MAIL/FAX to the
New Jersey Department of Health and Senior Services
Division of Epidemiology, Environmental, and Occupational Health
PO Box 369
Trenton, NJ 08625-0369
FAX: (609) 588-2516
PHONE: (609) 588-8536
ATTN: _Mary T. Glenshaw, PhD, MPH
_________________________