PATIENT CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION

Patient Name:

Birth Date:

I hereby authorize Skagit Pediatrics and provider(s) to disclose or release confidential health care information as described below:

Exchange information with Send to Request From

Name of Provider, Agency, or Facility:

Address:

City, State, ZIP:

Phone:

Fax:

If Phone Contact, Please input below

Other

Patient must initial each to allow release. Specific Authorization is required for minors for the following:

Drug/Alcohol

I understand that my records may contain information regarding diagnosis or treatment for drug or alcohol abuse. I give my specific authorization for these records to be released.

(Minors, 13 years of age or older must sign)

Initial

AIDS/HIV/STD

I understand that my records may contain information regarding testing, diagnosis or treatment of HIV/AIDS or sexually transmitted diseases. I give my specific authorization for these records to be released.

(Minors, 14 years of age or older must sign)

Initial

Mental Health

I understand that my records may contain information regarding diagnosis or treatment for diagnosis or treatment for mental health diagnosis. I give my specific authorization for these records to be released.

(Minors, 13 years of age or older must sign)

Initial

Disclosure of information authorized herein is required for the following purpose(s):

Unless cancelled earlier by me, this authorization will remain in effect for 364 days after date of signature.

This information shall be kept confidential and further disclosure to any other person/organization is prohibited without my specific written consent or as otherwise specified by law. I understand I may revoke this authority at any time, except to the extent that action has already been taken. To revoke this authorization, the request must be in writing to the Skagit Pediatrics Medical Records Department. SKP is prohibited from conditioning treatment, payment, enrollment, or eligibility for benefits on my agreement to sign this authorization. I understand that the information used or disclosed as described by this authorization may no longer be protected by federal law and could be used re-disclosed by the receiving party. A copy or fax shall be considered valid in lieu of the original.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature

Date of Signature

Parent/Guardian/Legal Representative Signature

Date of Signature

Your information will be encrypted.