Authorization to Release/Not Release Medical Information

Patients Name:

Last Name:

First Name:

Phone Number:

To Release:

, give permission to University Pediatric Associates, staff to discuss any medical conditions with my Parent(s)/Guardian(s).

This includes providing them with any copies of my medical records as requested by them.

This authorization will remain in effect until I choose to retract it.

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.

Signature:

Date:

To Not Release:

, decline giving permission to University Pediatric Associates staff to discuss any medical conditions with my Parent(s)/Guardian(s).

This includes providing them with any copies of my medical records as requested by them.

This authorization will remain in effect until I choose to retract it.

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.

Signature:

Date:

Your information will be encrypted.