EFFECTIVE APRIL 14, 2003, THE FOLLOWING POLICY WILL BE ADHERED TO FOR ALL RELEASES OF MEDICAL INFORMATION
No Medical Information will be released without written consent from either Parent/Legal Guardian for minor children under 18.
Children over 18 MUST SIGN FOR THEIR OWN RECORDS.
Any HIPAA protected sensitive Information may also require the chi ld's signature if the child is over the age of 12.
Authorization for Release of Medical Information
AUTHORIZATION VALID FOR : (Check one.)
I understand that:
My right to healthcare treatment is not conditioned on this authorization.
I may cancel this authorization at any lime by submitting a written request to the address provided at the top of this form, except where a disclosure has already been made in reliance on my prior authorization.
If the person or facility receiving this information is not a health care or medical insurance provider covered by privacy regulations, the information slated above could be redisclosed.
Release of HIV-related information, mental health related care, or substance abuse diagnosis and treatment information requires additional authorization.
There may be a charge for the requested records.
NOTE: Medical records are faxed in cases of medical necessity only.
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.
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