Patient Authorization for Release of Protected Health Information
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
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
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