the parent or legal guardian of the below named child(ren).
Until we are notified in writing, Poole and Thomas Pediatrics will assume that a child’s biological and/or legal parents are both legal guardians who have access to treatment options and medical information for that child.
I hereby authorize and consent to the examination/treatment of my child(ren) during the office and facility visits by the physician and clinical staff of Poole and Thomas Pediatrics. In addition, I give permission for the following person(s) to bring my child to Poole and Thomas Pediatrics in my absence and to act on my behalf in authorizing medical care and treatment.
Anyone not mentioned above who brings your child into the office for treatment must have a signed authorization from the child(ren)'s legal guardian.
At Poole and Thomas Pediatrics, we are committed to protecting the security and privacy of your child’s personal information. Medical records are the property of Poole and Thomas Pediatrics. These records are kept in a secure location, and are accessed only for the purposes outlined by the Notice of Privacy Practices (Revised 9/23/13). Our revised Privacy Notice is available at www.ptpediatrics.com , or you may request a copy from our office. Records may be released or shared with other healthcare professionals for the treatment of your child. Patients are entitled to one free copy of their medical records only after an authorization for release is signed. Additional copies may be made for a fee of $1.00 per page, per KY House Bill 250.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
The purpose of this form is to obtain authorization for use or release of protected health care information. Patients have the right to receive one free copy of their medical records. There will be a charge for any additional requests.
PLEASE DO NOT FAX MEDICAL RECORDS
PATIENT INFORMATION:
Records From:
Records To:
INFORMATION REQUESTED:
I hereby request and authorize the release of requested health care information from the above named party to the corresponding above named party. This authorization will expire 60 days from the date signed. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to Poole and Thomas Pediatrics.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.