Authorization For Patient 18 Years & 3rd Party Release

PARENT/PATIENT MUST PROVIDE THE FAX NUMBER IF THIS IS THE REQUESTED FORM OF DISCLOSURE OR INFORMATION WILL NOT BE SENT.

Patient's Full Name

Date of Birth

SUMMERWOOD PEDIATRICS is authorized to release protected health information about the above-named patient to the entities listed below:

Patient Cell No. / Voicemail

Patient Email address

Patient Work / Home Fax No.

ENTITY TO RECEIVE INFORMATION

Check each person/entity that you approve to receive information

Parent Information (provide name / names)

Add Additional Name

School Information (provide name / names)

School Name

School Year

Contact Person

Phone No.

Fax No.

Daycare Information (provide name / names)

Day Care Provider

Contact Person

Phone No.

Fax No.

Other (provider/specialist/person)

Add Additional Provider

DESCRIPTION OF INFORMATION TO BE RELEASED

Check each box for information that can be shared with the person/entity listed above.

Financial Information

Medical: Without Restrictions (this includes mental health, labs & STI results)

Results: Lab test, Imaging

Physical form, Notes, Letters, Immunizations

Medication form: School or Daycare

Daycare forms

Ongoing verbal exchange of Mental Health Information (School Therapist-only if this box is checked)

Ongoing verbal exchange of Medical Information (School only- if this box is checked)

Other

If other, please specify

If you would like to restrict medical information released, check the box below and list what you would like restricted.

Restrictions for any Medical or Mental Health records/verbal exchange as follows:

PATIENT INFORMATION: I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or receive a copy protected health information to be disclosed as described in this document. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I acknowledge and am aware of the security risks associated with unsecure transmission of my personal health information. By signing this form, I accept the risks and agree to have my personal health information sent by the method indicated above. I understand that information used or disclosed because of this authorization maybe be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. I understand that have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing.

THIS AUTHORIZATION IS ONLY IN EFFECT FOR ONE YEAR FROM THE DATE OF SIGNATURE

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.

Patient/Parent/Legal Guardian Signature

Date

Your information will be encrypted.