Union Mill Pediatrics, P.C.
This form is to be used to authorize certain and specific access to the medical records of patients who are over the age of 18 years.
I understand that my right to confidentiality will be protected, regardless of insurance coverage or relations, and that no information will be released to or discussed with other parties without my express permission and that of my physician. I understand that I can withdraw this authorization at any time.
I, (Patient Name), authorize access only for those items indicated and initialed below
(CHECK BOX AND INITIAL EACH SELECTION)
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.