Authorization for Use and Disclosure of Protected Health Information

Consent to release Protected Health Information (PHI)

Please correct the errors described below.

I understand that in order to disclose my PHI, Ennis Pediatrics, must have my consent, therefore, I authorize Ennis Pediatrics to disclose my PHI as described in the provided forms, to the recipients listed below:

Name(s) of the person(s) authorized to obtain the above mentioned information. (e.g. Physician other than your referring doctor, family members and other specified person/persons)

Contact Information:
I authorize Ennis Pediatrics to contact me at the following number with results or questions:

May we leave a detailed message on your answering machine or voicemail?

In signing this HIPAA Patient Acknowledgement form, you acknowledge and authorize, that you hold harmless this Healthcare Facility, its employees and agents for any and all liability (including but not limited to negligence) arising out of or occurring from this authorization. I understand that my records may be subject to re-disclosure by recipient(s) and unprotected by federal or state law; that this authorization remains effective until this Healthcare Facility is in actual receipt of a signed revocation or until the records retention period required under federal and state law has expired and the records have been destroyed; that I have the right to revoke this authorization at any time, provided I do so in writing; that I have been given the opportunity to ask question; that I have received a copy of the signed authorization; that I may inspect a copy of my PHI to be used or disclosed under this authorization; that his Healthcare Facility has not conditioned provision of services to or treatment of me upon receipt of this signed authorization; and that I may refuse to sign authorization. A copy of this signed, dated authorization shall be as effective as the original.

Your information will be encrypted.