Patient Authorization to Release Health Information

Patient Information:

Name of Patient

Date of Birth

Address

City, State, Zip

Phone

Entity or person who will receive the information

Doctor Office/Name

Address

City

State

Phone

Fax

Entire record

Office visit notes

Diagnostic studies (list)

Other as listed

Entity or person who will release the information

Doctor Office/Name: ALABASTER PEDIATRICS

Address: 1004 1ST STREET NORTH, SUITE 370 ALABASTER AL 35007

Phone: 205-663-5547

Fax: 205-663-1990

This authorization shall be in effect until the information has been forwarded as requested or until the course of treatment is complete.

I have the right to revoke this authorization at any time.
I may inspect or copy the protected health information to be disclosed as described in this document.
Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.
I may refuse to sign this authorization and that my treatment will not be conditioned on signing.
I understand released information may include a communicable disease diagnosis such as HIV.

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 or Personal Representative

Date

Description of Personal Representative’s Authority (attach necessary documentation)

Your information will be encrypted.