Over 18 HIPAA Release and Consent Form

Please correct the errors described below.

I understand and acknowledge that as of my 18th Birthday, my parents and/or guardians will no longer be permitted access to my medical records, information, providers, or appointment status without my specific written permission. Children's Healthcare Associates (CHA) will not speak with my parents, permit my parents to schedule appointments or release medical information to my parents without my written consent in accordance with this document.

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.

This consent is valid for one year from the date signed. I understand that I can withdraw consent at any time by providing Children's Healthcare Associates with written notice indicating the changes in access.

Your information will be encrypted.