Pediatric Associates of Denham Springs

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.

Patient Name:

Date of Birth

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

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

Name

Pediatric Associates of Denham Springs

Address

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

Phone

Fax

Phone: (225) 665 - 6677

Fax: (225) 665- 0055

SECTION B:

Need copy of records for (Please check one)

Personal Use Moving School Changing Doctors

SECTION C:

Check information that may be used/disclosed: (Include dates where appropriate)

Entire Medical Record

Record of Visit(Specific)

Laboratory Report(s)

Consultation Report(s)

Immunization Record

Physical/History Report

Radiology Report(s)

Mental Health

Cardiology Report(s)

Other

SECTION D:

Check which format you want to request

Digital (on a CD) Paper

If you choose Paper: Please Choose One

Faxed Pick up at office

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.

Signature/Name of Patient or Representative

Today's Date

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.

Relationship to Patient

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