Authorization for Release of Patient Health Information

Name

Date of birth

Address

City/State/Zip

Telephone

I hereby authorize the protected health information regarding the above-named person be forwarded

Person/Institution

Address

City/State/Zip

Phone

Fax

From

Person/Institution: Child and Adolescent Health Associates
Address: 1030 N Clark St, 4th floor
City/State/Zip: Chicago, IL, 60610
Phone: 312-943-6964
Fax: 312-943-6924

I authorize the release of information covering the period(s) of healthcare from

Date(s)

To Dates(s)

The type of information to be used or disclosed is as follows

History and physical examination

Consultation reports

Progress notes

Discharge summary

Operative reports

Verbal only

Abstract (summary of health hx)

Diagnostic tests (labs, xrays, etc)

Other

This information for which I am authorizing disclosure will be used for the following purpose

My personal use (there is a fee for personal use copies)

Sharing with other health care providers (no charge if sent directly to the provider-address must be provided as recipient above)

Other

This authorization will expire

If not otherwise specified this release will expire within 30 days of the date of signature.

I understand that Child and Adolescent Health Associates may, directly or indirectly, receive remuneration from a third party in connection with the use and disclosure of my health information. I understand that I have the right to inspect and obtain a copy of any information about mental health, drug and alcohol, or developmental disability services that is disclosed pursuant to this Authorization. I have read and understand the terms of this Authorization and I have had the opportunity to ask questions about the use and disclosure of my health information. By my signature, I hereby, knowingly and voluntarily authorize Child and Adolescent Health Associates to use or disclose my health information in the manner described above.

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.

Name of Patient or Legal Guardian

Signature of Patient or Legal Guardian

Date

Your information will be encrypted.