PARENT/PATIENT MUST PROVIDE THE FAX NUMBER IF THIS IS THE REQUESTED FORM OF DISCLOSURE OR INFORMATION WILL NOT BE SENT.
SUMMERWOOD PEDIATRICS is authorized to release protected health information about the above-named patient to the entities listed below:
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If you would like to restrict medical information released, check the box below and list what you would like restricted.
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
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