Authorization to Release Medical Information

I understand that my child’s medical records are confidential and cannot be disclosed without my written authorization. Except otherwise provided for by law, I hereby voluntarily authorized

Phone

to release the following information for

Patient Name

DOB

The information specified below may be release to:

Name

Address

City

State

Zip Code

Telephone

Fax

The specific purpose(s) for this disclosure is/are:

My personal use

Sharing with other healthcare providers

Other

If other, please specify.

I want

I Do Not Want

you to include information pertaining to the diagnosis and/or treatment of HIV testing, AIDS, psychiatric illness, and alcohol and/or chemical abuse and dependency if any

SPECIFIC INFORMATION TO BE RELEASED: (please check all that you are requesting to be released)

Complete Medical Record for this office

History & Physicals

Immunization Records Only

Diagnostic Testing & Results

Other

If other, please specify.

I understand there is a $25 fee, per child for medical records. I also understand fees for copies are due and payable before copies are released. text

I understand this authorization expires 180 days from the date signed

I understand that once the above information is disclosed, it may be re-disclosed by the recipient and the information may not be protected by federal privacy laws or regulations.

I understand that photocopy or facsimile of this authorization is as valid as the original.

I understand that I may revoke this authorization at any time by notifying this office in writing and that such revocation will be not have any actions taken by this office before this revocation.

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.

Signature of Patient, Parent 0r Legally Authorized Guardian

Date

Print Name

Relationship to Patient

Your information will be encrypted.