Please correct the errors described below.

Records may be released to: Grandville Pediatrics, 2845 44th St Suite 200, Grandville, MI 49418

I authorize Grandville Pediatrics, PC to release/receive information contained in my patient records, including, as applicable:
Information about communicable diseases and serious communicable diseases and infections, as defined by statute and Michigan Dept. of Public Health Regulations, which includes Venereal Diseases, Tuberculosis, Hepatitis B, HIV, HIV test, AIDS, and AIDS-related complex (ARC)

Alcohol and drug abuse treatment information protected under the regulations in 42 code of the Federal Regulations, Part 2.
Mental Health treatment records, psychological services, and social services information, including communications made by me to a social worker or psychologist.

It is further understood that the information released is for the purpose stated above and may not be provided in whole part or in part to any other agency, organization or person. I may revoke this Authorization at any time by notifying Grandville Pediatrics in writing at the address listed above. The revocation will not be effective for information that Grandville Pediatrics discloses between the time that this Authorization is signed and when the revocation is received. I understand that the persons to whom information is disclosed under this Authorization may possibly redisclose the information to others without my knowledge or consent, and therefore, the privacy of my personal and health information may no longer be protected by law.
This Authorization will expire one year from the date signed unless an expiration date is listed.

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