Patient Authorization for Release of Protected Health Information
I request the following information to be disclosed to:
Northwest Suburban Pediatrics, S.C.
455 S. Roselle Rd. Suite 209
Schaumburg, IL 60193
Phone: 847-352-9910 I Fax: 847-352-4471
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
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.