Authorization for Use and Disclosure of Protected Health Information

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:

Description of the information to be disclosed (check all that apply)

All Procedures

Test Results

Appointments

Other

Surgeries

Billing/Account Information

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)

Name:

Relationship:

Name:

Relationship:

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

Home

Cell

Work

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

(Failure to check one of these boxes may delay results.)

Yes No

By Patient: (Print and Sign)

Date field

Or Patient’s Representative (Print name, sign and describe authority)

Date field

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.

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