Authorization for Release of Medical Records

Patient’s Legal Name

Date of Birth

Address

City

State

Zip

Social Security Number

Phone Number

I hereby authorize

Previous Physician

Phone Number

Fax Number

to release the following medical information to:

Prestige Pediatrics

600 Pointe North Blvd.

Albany, GA 31721

Office: 229-903-4044
Fax: 229-903-4055

If other, please specify

I understand that this information may include any history of acquired immunodeficiency syndrome (AIDS): sexually transmitted diseases; human immunodeficiency virus (HIV) infection; behavioral health service/psychiatric care; treatment for alcohol and/or drug abuse, or similar conditions.

I understand that I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing to the Prestige Pediatrics except to the extent that the practice has acted in reliance upon this authorization. I do not have to sign this authorization in order to receive treatment. I may inspect or obtain a copy of the information to be used or disclosed. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: (If I do not specify expiration date, event, or condition, this authorization will expire on the following date, event, or condition, this authorization will expire in six months.)

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 of Parent/Legal Guardian

Relationship to patient if acting for the patient

Date

Your information will be encrypted.