AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

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.

Name of Child

Date of Birth

Please release the following information:

complete medical record (to include immunization record).

fax immunization record only

other (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.):

We cannot disclose certain information unless specifically authorized to disclose this information. Please initial next to each item below if you specifically authorize the release of health information relating to the testing, diagnosis, or treatment for:

HIV/AIDS

Drug and alcohol abuse

Mental health/psychiatric disorders

TO FROM

Name

Name:

Oak Park Pediatrics

Address

Address:

1107 Chicago Ave

City

City:

Oak Park

State/Zip Code

State/Zip Code:

IL, 60302

Phone

Phone:

708-383-2900

Fax

Fax:

708-383-2969

Release information via

pick up

mail

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.

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 Parent or Legal Guardian

Date

Guardian Relationship to Patient

Name of Parent or Legal Guardian

Your information will be encrypted.