Patient Authorization for Use and Disclosure of Protected Health Information

Patient First Name:

Patient Last Name:

Date of Birth:

Add another patient

Street Address:

City, State, Zip:

Phone #:

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

Party to RECEIVE my health information:

Name:

Address:

City, State, Zip:

Phone #:

Fax #:

Party to RELEASE my health information:

Name:

Address:

City, State, Zip:

Note: Bloomington Pediatrics is unable to send or accept records on CD.

Acceptable methods are paper, fax, secure email, or encrypted USB drive.

PURPOSE OF DISCLOSURE:

Moving to a new location:

Specialist Referral:

Changing Insurance:

Patient Request:

Other:

DESCRIPTION OF MY HEALTH INFORMATION TO BE DISCLOSED:

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

Routine Records

Specific Records Only

Complete Chart

Please specify:

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, LTD, 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.

Patient Name/Signature:

Date:

Relationship if not patient:

WITNESS:

Your information will be encrypted.