Authorization to Release/Not Release Medical Information

for patients 18 yrs old or older

Please correct the errors described below.

Patients Name:

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.

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.

Your message will be encrypted.