Authorization to Use or Disclose Protected Health Information

This authorization may be used to permit a covered entity (as such term is defined by HIPAA and applicable Florida law) to use or disclose an individual’s protected health information. Individuals completing this form should read the form in its entirety before signing and complete all the sections that apply to their decisions relating to the use or disclosure of their protected health information

Information regarding patient for whom authorization is made:

Full Name:

Other Name known by:

DOB:

Request records from:

Name:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Send records to:

Cepero Pediatrics
3488 Depew Ave.
Port Charlotte, FL 33952
Phone: (941) 764-7923 Fax: (941) 764-7927

Specific information to be disclosed:

Medical Record From:

Medical Record To:

Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records received from other health care providers.

Other

Include: (Indicate by Initialing)

Drug, Alcohol or Substance Abuse Records

Mental Health Records (Except Psychotherapy Notes)

Genetic Information (Including Genetic Test Results)

HIV/AIDS-Related Information (Including HIV/AIDS Test Results)

Reason for release of information: Check all that apply:

Personal Use

Billing or Claims

Disability Determination

Transfer of Medical Care

Legal Purposes

Insurance

Other

If Other, Please Specify:

The individual signing this form agrees and acknowledges as follows

I. Voluntary Authorization

This authorization is voluntary. Treatment, payment, enrollment or eligibility for benefits (as applicable) will not be conditioned upon my signing of this authorization form

II. Effective Time Period

This authorization shall be in effect for one year from the date signed or the following specified date:

Date:

III. Right to Revoke

I understand that I have the right to revoke this authorization at any time by writing to the health care provider or health care entity listed above. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

IV. Special Information

This authorization may include disclosure of information relating to DRUG, ALCOHOL and SUBSTANCE ABUSE, MENTAL HEALTH INFORMATION, except psychotherapy notes, CONFIDENTIAL HIV/AIDS-RELATED INFORMATION, and GENETIC INFORMATION only if I place my initials on the appropriate lines above. In the event the health information described above includes any of these types of information, and I initial the corresponding lines in the box above, I specifically authorize release of such information to the person or entity indicated herein.

V. Signature Authorization

I have read this form and agree to the uses and disclosure of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy laws

SIGNATURES

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.

Patient/Legal Representative

Date:

If Legal Representative, relationship to Patient:

Witness (optional):

Date:

A minor individual's signature is required for the release of certain types of information, including for example, the release of information related to certain types of reproductive care, sexually transmitted diseases, and drug, alcohol or substance abuse, and mental health treatment.

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.

Signature of Minor (if applicable):

Date:

Your information will be encrypted.