PATIENT AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION FOR PURPOSES REQUESTED BY PRACTICE
By signing this authorization, I authorize Pediatric Associates of Lawrenceville, LLC (PAL) to use/or disclose certain protected health information (PHI) about
This authorization permits PAL to use and/or disclose the following individually identifiable health information (specifically describe the information to be used or disclosed, such as date(s) of services, type of services, level of detail to be released, origin of information, etc.):
The information will be used or disclosed for the following purposes:
Insurance information, further medical care, immunization forms to schools, daycare, college forms, camp forms ,sports physical forms, and to call prescriptions to pharmacy.
The purpose(s) is/are provided so that I can make an informed decision whether to allow release of the information. This authorization will expire in 365 days. At which point you will be asked to review and sign an updated copy.
will not receive payment or other remuneration from a third party in exchange for using or disclosing the PHI.
I do not have to sign this authorization in order to receive treatment from PAL. In fact, I have the right to refuse to sign this authorization. I also have the right to inspect or copy the information to be used or disclosed. When the information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy rule. I have the right to revoke this authorization in writing except to the extent that the Practice has acted in reliance upon this authorization. My written revocation must be submitted to the Privacy Officer at:
738 Old Norcross Road
Lawrenceville, Georgia 30046
I acknowledge receipt of the Notice of Privacy Practices of Pediatric Associates of Lawrenceville, LLC.
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.
As the personal representative, I have the authority to act for the Patient because I am the Patient’s
Your information will be encrypted.