Medical Release Form Incoming - Fayetteville - AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Patient Last Name

Patient First Name

Middle Initial

Date of Birth

I authorize the following organization to release all health care information as stated below to the organization listed:

Information to be release to:

Tri-County Pediatrics
1240 Hwy 54W Suite 100
Fayetteville, GA 30214

Information to be released from:

Organization/Person Name

Street Address

City, State, Zip

Telephone/Fax Number

THIS REQUEST APPLIES TO (Charges for copies of records may be associated with your request)

Transferring Physicians
Continued Medical Care
Legal Action/Review
Insurance Requirement
Other

If other, please specify:

Daytime Telephone

Address

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.

I understand this authorization will expire in 90 days after the date below and covers only treatment prior to that date. I understand that I may revoke in writing this authorization at any time. I understand that the information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer be protected by federal privacy law. I acknowledge that a revocation will not affect actions already taken in reliance on the authorization form. I also consent to the release of medical information which may contain treatment for physical and/or emotional illness, communicable disease, alcohol or drug abuse treatment, and/or HIV, AIDS, or AIDS related information. I understand this authorization will expire in 90 days after the date below and it covers only treatment prior to that date. I also understand that I may revoke in writing this authorization at any time.

Signature

Date

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