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Rebecca Jude Grillo P.A. fax number

(203) 672-2801

Physician Assistant

Used for: Medical records requests and other patient communications (e.g., authorization to release medical information).

Fax destination details

Department
Physician Assistant
Purpose
Medical records requests and other patient communications (e.g., authorization to release medical information).
Form
Authorization to Release Medical Information (HIPAA Release Form) — Authorization to Release Medical Information
Address
52 Washington Ave, Suite 4, North Haven, CT 06473-1724
Voice phone
203-672-2800

Before you send

  • Confirm that this exact department handles your document or request.
  • Check the organization website or call its main line for the current fax number.
  • Include a cover sheet and any case, member, claim, or form reference required.
  • Keep the delivery confirmation with your submission records.

Complete patient name, date of birth, contact information; indicate the agency/clinic to receive the records; specify date range if needed; sign and date the form. Submit to the medical records department or the contact listed by the practice.

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