DUNWOODY PEDIATRICS
PEDIATIRC AND ADOLESCENT MEDICINE
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JULIUS SHERWINTER, MD, FAAP
A. GERALD REISMAN, MD, FAAP
GLORIANA BERENSON, MD, FAAP
TERRENCE GFROERER, MD, FAAP
STEPHANIE JERNIGAN, MD, FAAP
LINDA S. KELLY, MD, FAAP
KELLY WILBURN, MD
MICHELE WHITEN, MSN CNP
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PATIENT NAME
DOB
RELEASE OF INFORMATION
I AUTHORIZE THE RELEASE OF ANY MEDICAL OR OTHER INFORMATION
NECESSARY TO PROCESS MY CHILD’S INSURANCE CLAIM. THIS INCLUDES
THE
RELEASE
OF
MEDICAL
INFORMATION
TO
THER DOCTORS
OR
INSURANCE COMPANIES FOR REFERRALS OR CONTINUING MEDIAL CARE. I
AUTHORIZE PAYMENT OF MEDICAL BENEFITS TO DUNWOODY PEDIATRICS
FOR SERVICES RENDERED. I AGREE TO PAY DUNWOODY PEDIATRICS FOR
ANY SERVICES NOT APPROVED OR COVERED BY MY INSURANCE COMPANY.
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SIGNATURE OF PATIENT/PARENT/GUARDIAN
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Dunwoody Village. 5501 Chamblee Dunwoody Road. Dunwoody, GA 30338. 770-394-2358
Kid’s Village. 5075 Abbotts Bridge Road. Suite 800. Alpharetta, GA. 30022. 770-664-9299