Protected Health Information Consent

By signing below, I understand that if I so choose, the individuals or agencies I have listed will be given access to my PROTECTED HEALTH INFORMATION from Associated Pediatricians, LLC.

CHOOSE FROM THE FOLLOWING:

I do not wish to designate a personal healthcare representative with respect to my protected health information at this time.

I hereby grant permission to Associated Pediatricians, LLC to disclose my protected health information to those names listed below.

I hereby by grant permission to Associated Pediatricians, LLC to disclose to disclose my protected health information and give access to my patient portal account to those names listed below.

Additional Name

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

Patient Name / Signature

Date

Responsible Party Signature

Date

Your information will be encrypted.