Patient Authorization for use and Disclosure of Protected Health Information Form

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I AUTHORIZE THE DISCLOSURE OF MY PERSONAL HEALTH INFORMATION AS FOLLOWS:

Party to RECEIVE my health information:

Party to RELEASE my health information:

PURPOSE OF DISCLOSURE:

DESCRIPTION OF MY HEALTH INFORMATION TO BE DISCLOSED:

Bloomington Pediatrics & Allergy can only release documentation created by our facility, physicians, and staff.

This authorization is valid for 1 year unless I cancel this authorization in writing before it expires. The cancellation must be dated and signed. It must be delivered to the Privacy Officer at Bloomington Pediatrics and Allergy, 306 St. Joseph Dr., Bloomington, IL 61701. I understand the health information disclosed by this authorization may be redisclosed by the recipient and may no longer be protected by the federal HIPAA Privacy Rule.

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.

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