AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
Please correct the errors described below.
By signing this authorization, I authorize you to release confidential health information about my child by releasing a copy of her or his medical records or other protected health information (PHI), to the person(s) or entity listed below.
Oak Park Pediatrics
1107 Chicago Ave
I do not have to sign this authorization in order for my child to receive treatment from Oak Park Pediatrics Ltd. I understand that the party releasing information may charge a fee for preparing and furnishing this information.
Unless revoked in writing, this authorization will expire after 60 days or upon receipt of the requested medical record from the party to whom information is directed to be released.
I understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and no longer be protected by the Health Insurance Portability and Accountability act of 1996. The party authorized to release information, its employees, officers and physicians are hereby released from any legal responsibility for disclosure of the above information to the extent indicated and authorized herein.
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