Request to Transfer Medical Records

I hereby give DuPage Pediatrics, Ltd. permission to release my child’s Protected Health Information (PHI) to:

(Full name & address must be complete to release records)

I authorize the specific records chosen below to be released to the entity listed above:

(Please choose only ONE)

STD/HIV, Behavioral Health, Genetic Testing and Drug/Alcohol Abuse treatment information contained within the dates of service I have specified above are to be released through this authorization unless specified below:

I am requesting my child’s PHI to be disclosed for the following purpose:

I may revoke this authorization at any time by mailing or personally delivering a signed written notice of revocation to the healthcare provider at which this authorization was executed. Such revocation will be effective upon receipt, except to the extent that the recipient has already taken action in reliance on this Authorization. I am entitled to a copy of this authorization upon my request. I may not be required to sign this Authorization as a condition to obtaining treatment or payment or my eligibility for benefits. The recipient of this protected health information is prohibited from re-disclosing the information unless the recipient obtains another authorization from me or unless the disclosure is specifically required or permitted by law. Where permitted, the information I am requesting to be disclosed may sometimes be re-disclosed by the recipient and may no longer be protected by law. I am entitled to notice if my protected health information is used for marketing and results in remuneration to the provider. I hereby acknowledge that I have read and fully understand the above statements as they apply to me.

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.