AUTHORIZATION FOR USE & DISCLOSURE OF PROTECTED HEALTH INFORMATION
RELEASE RECORDS FROM:
RELEASE RECORDS TO:
By moving or transferring records you will be released as a patient of
Partners in Pediatrics after 30 days.
Names if Necessary
Record Release Authorization
By signing below, I authorize the use and disclosure of my protected health information as requested. I understand the information
may be re-disclosed by the recipient and may no longer be protected by the federal HIPAA privacy rule. I have the right to revoke
this authorization except to the extent that Partners in Pediatrics has acted in reliance upon this authorization.
**There will be a charge from Partners in Pediatrics in compliance with federal and/or state law.**
**All records will be provided in electronic format unless requested otherwise.**
Medical records received from your previous doctor are reviewed by your Partners in Pediatrics physician. After review your
records will be scanned into an electronic health record created for you. If you would like a copy of your records please notify our
medical records coordinator, otherwise they will be shredded for your privacy. Thank you!
Office Use Only
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.