New Jersey Medical Release Form 2
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Rutgers University
Robert Monaco, M.D., M.P.H.
Director of Sports Medicine
Hale Center
One Scarlet Knight Way
Piscataway, New Jersey 08854-8016
Ph. (732) 445-6258 * Fax (732) 445-2780

Medical

Release

Form

I, ____________________________________, hereby give consent for my medical
(Print Name)

Records (office notes, operative Reports, discharge hospital summary)
pertaining to the following problems which occurred on or around:
____________________________________________________________________________
to be released to Dr. Robert Monaco, Director of Sports Medicine at Rutgers
University.
The information to be released is requested for continuing medical care of the patient. This
authorization will expire six months from the date of the signature. You may revoke this
authorization to release private health information at anytime. Your continued ability to get
treatment and eligibility for benefits will not be affected by signing this document. By signing
this document you also unde