PERMISSION TO RELEASE MEDICAL INFORMATION 18 YEARS AND OLDER

Name:

DOB:

Address:

Phone:

PLEASE SELECT ONE OF THE FOLLOWING:

My medical information can be released to:

Release my medical information to my parents Release my medical information only to my mother Release my medical information only to my father Release my medical information to:

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.

SIGNATURE OF YOUNG ADULT (18 YEARS OF AGE AND OVER)

Date:

According to HIPPA Privacy Regulations, Northeast Pediatrics cannot disclose protected health information unless permitted by the regulations and procedures designed to protect this information. If the patient is 18 years of age or older, the patient must have a signed written release in his/her chart before any information can be released for the intended purpose or what has been specified on a HIPAA authorization.

A Patient-Centered Medical Home is a Partnership Between the Patient and his/her Physicians

Being a part of a Patient-Centered Medical Home, your Primary Care Physician will:

Work with you to improve your health
Review your medications at every visit and recommend changes if needed
Develop a plan with you to improve your health and manage any chronic health problems
Set health goals with you and monitor your progress to help you stay healthy
Use computer technology as needed to optimize your care
Inform you of all test results in a timely manner
Provide you with educational material and information about community programs that will help you improve your health
Provide 24 hour phone access to a medically trained professional (doctor, nurse or other provider)
Work with after-hours care centers to be informed of your visit within 24 hours
Offer same day appointments when needed

By choosing to participate in a Patient-Centered Medical Home, I agree to:

Make sure my doctor knows my entire medical history
Tell my doctor all of the medications I am taking
Actively participate with my doctor in planning my care
Keep my appointments as scheduled
Follow my doctor's recommendations
Frequently sign into my patient medical record portal to update my medical history, review messages, and communicate with my provider(s) when necessary
Ask my doctor questions about things do not understand
Ask my Primary Care Physician for advice before making an appointment with a specialist
Ask other health care providers to send my doctor information such as lab or test results, x-rays, or treatment notes
Understand my insurance, what it covers and update the office with changes
Provide the office feedback on how they can improve my care

Being a part of a Patient-Centered Medical Home Neighborhood, your Specialists will:

Communicate with your Primary Care Physician about treatment plans, medications, test orders and test results
Support the treatment plans and health goals set by your Primary Care Physician
Have an agreement with your Primary Care Physician regarding who will have the lead responsibility for your care if a chronic disease exists
Have same day appointments available for urgent problems and appointments within 1-3 weeks available depending on your medical needs
Work with your Primary Care Physician to coordinate all aspects of your care

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.

Patient Signature:

Date:

RECORDS RELEASE AUTHORIZATION*

I HEAREBY AUTHORIZE AND REQUEST THE RELEASE OF RECORDS FOR THE FOLLOWING PATIENT (S):

Add Name

SEND TО:

These records are being released for the following reason:

Moving to a new area

Patient has outgrown pediatrics

N.E. Pediatrics does not participate with your insurance. If so, list insurance carrier:

Transferring to a new pediatrician due to dissatisfaction with:

Waiting time in office.

Pediatrician's care of child.

Nursing Staff.

Interactions with staff.

Difficulty scheduling timely appointments

Other

If Interactions with staff, Name?

If Other, specify:

I authorize the release of these medical records including mental health, chemical dependency, and any other infectious diseases.

TELEPHONE NUMBER:

DATE

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.

AUTHORIZING SIGNATURE:

RELATIONSHIP:

Office use only:

Date sent:

Sent by:

MEDICAL for RECORDS a copy ACCESS ACT, SECTION 333.26269 If a patient or his authorized representative makes a of all or part of his medical record under Section 5, the health care provider, health facility, or medical records company to which the request is directed may charge the patient or his authorized representative a fee that is not more than the following amounts.
Paper copies as follows:
One dollar per page for the first 20 pages; no more than $25 for the complete file.

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