Pediatric Associates of Denham Springs

Authorization for Release of Information - Part-One

Please correct the errors described below.

SECTION A:

Must be completed for all authorizations.

I hereby authorize the use/disclosure of my information as described below. I understand that this authorization is voluntary. I understand that any and all records, whether written, oral or in electronic format are confidential and cannot be disclosed without prior written authorization except as otherwise provided by the law. I understand that a photocopy or fax of authorization is as valid as the original.

Person(s)/organization authorized to use/disclose the information (TO):

Pediatric Associates of Denham Springs

1213 N. Range Ave. D.S., LA 707226

Phone: (225) 665 - 6677

Fax: (225) 665- 0055

SECTION B:

SECTION C:

SECTION D:

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your message will be encrypted.