Medical Release Form Incoming - Fayetteville

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:

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

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.