Release of Information Form

    To Medical Records Department / Health Information Management,

    I, consent to the release of my medical information requested below, to Rajesh Malik M.D., ReAnna Gibbs P.A.C., and/or Miranda Turner PA-C.


    Please include the following with the records: • My recent Lab work records • My recent Visits • My Immunization records • My records from other physicians sent to you in past • My Medication lists • My Radiology procedure results

    Please send the information to: Attention: Medical Records Mullica Hill Medical & Wellness 201 Bridgeton Pike Mullica Hill NJ 08062 Tel: 856 478 2111 Fax: 856 478 4709 Sincerely,