Authorization for Release of Protected Health Information

I. Patient’s Name

Birth Date

Patient’s Address

Home Phone

City, State, Zip

II. Records released to

Mailing Address

Phone Number

City, State, Zip

Fax Number

III. Records released from: North Oaks Pediatric Clinic, LLP

Mailing Address

Phone Number

City, State, Zip: Hammond, LA 70403

Fax Number: (985) 318-6402

IV. Purpose of disclosure:

Application for Insurance

Legal - Custody

Processing of Insurance Claim

Legal - Lawsuit

Changing Doctors

Moving

Other

If other, please specify.

I hereby acknowledge, and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, AIDS information, or genetic information, which may have specific statutory protection.

For Treatment dates

This authorization will expire on

If I fail to specify a date or event, this authorization will expire one year from the date on which it was signed.

Any and all records, whether written or oral or in electronic format, are confidential and cannot be disclosed without my prior written authorization, except as otherwise provided by law.
A photocopy or fax of this authorization is as valid as this original.
I may revoke this authorization at any time, except where information has already been released. This authorization is valid for one year period from the date it is signed, or sooner if noted above. The revocation must be in writing. A revocation form is available from the Medical Records department.
North Oaks Pediatric Clinic, L.L.P., it’s employees, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.
Treatment, payment, enrollment or eligibility for benefits may not be conditioned upon obtaining this Authorization.
Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and is no longer protected.
This completed form authorizes North Oaks Pediatric Clinic (“NOPC”) to disclose a patient’s protected health information to a third party.
NOPC reserves the right to verify my identity/guardianship.

Patient/Legal Guardian

Relationship to Patient (if other than self)

Social Security Number

(Last 4 for Identification Purposes Only)

Date

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