Authorization for Release of Health Information From Us

Please correct the errors described below.

I hereby authorize Caring Hands Children’s Clinic to release the following records:

I understand that:

  • This Authorization is valid for one year from date signed, unless I revoke/withdraw this Authorization in writing or unless an earlier date is specified here: __. I may revoke/withdraw this Authorization, except to the extent that action has been taken prior to receipt of the revocation/withdrawal, by mailing or faxing my written request the clinic or department where my Authorization was made or given. A photocopy is as valid as the original.
  • Once My Health Information is disclosed as requested, it may no longer be protected by federal and state privacy laws, and could be redisclosed by the person(s) receiving it.
  • The medical information released may contain information related to HIV status, AIDS, sexually transmitted diseases, mental health, drug and alcohol abuse, etc.

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.

If you are NOT the patient but are signing on behalf of the patient, please complete below:

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.