Records Release Auth. (Transfer In)

Transfer In Form

Patient Authorization for Release of Protected Health Information

Child's Last Name:

Child's First Name:

Date of Birth:

Telephone Number:

Previous Physician's Name:

Address:

Phone / Fax:

I request the following information to be disclosed to:
Northwest Suburban Pediatrics, S.C.
3335 N. Arlington Hts. Rd. Ste. C
Arlington Heights, IL 60004
Phone: 847-788-8300 I Fax: 847-788-8306

Please check the appropriate box and include specific dates if necessary.

Physician Visit Notes

Lab Reports

Immunizations

X-ray Reports

Complete Chart

Other

If other, specify:

Specific Dates:

Patient Signature or Legal Guardian:

Date:

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

I understand that this information disclosed could contain mental health, genetic testing, developmental disabilities, alcohol and drug abuse, and/or Acquired Immune Deficiency Syndrome (AIDS/HIV) information. I understand that I have the right to inspect and/or obtain a copy, (for the appropriate fee) of the information prior to disclosure. When my information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I may revoke this authorization at any time (except to the extent that action has already been taken) by submitting a written revocation to the Privacy Officer of Wee Care Pediatrics at the office address. This authorization will expire 90 days from today's date.

For Office Use Only

Reviewed by: (initials / date)

Processed by: (initials / date)

Your information will be encrypted.

Records Release Auth. (Transfer In)

** Transfer In Form **

Patient Authorization for Release of Protected Health Information

For Office Use Only

Transfer In Form