Authorization For Release Of Information

Pediatric Health Center of Conyers

Please correct the errors described below.

I authorize the release of medical information as indicated below:

FROM:

TO:

werwer
werwer

Note: The records listed below have special protection by laws. I authorize the release of information pertaining to:

to transmit or deliver such information electronically.

Expiration date: This authorization will expire in sixty days unless otherwise indicated below:

This request must be made in writing and sent to the same place as the original request. Attach a copy of this release if possible. Treatment, payment, enrollment in any health plan is not conditioned on signing this authorization.

and may potentially be re-disclosed by the party who received these records. its employees and officers, and attending physicians are released for legal responsibility or liability for release of the above information to the extent indicated and authorized.

I understand that I have the right to:

  • Inspect or copy the Protected Health Information to be used or disclosed as permitted under federal law (or state law to the extent the state law provides greater access rights.)
  • Have an electronic copy of my medical records, or a portion thereof, transmitted to any third party or person I designate.
  • Refuse to sign this Authorization.

I have read and understand this information. I have received a copy of this form and I am the patient or am authorized to act on behalf of the patient to sign this document verifying authorization for the use or disclosure of the protected health information under the above stated terms.

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

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

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