AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (18YRS+)

By signing this authorization, I authorize Oak Park Pediatrics to release confidential health information by releasing a copy of my medical records or other protected health information (PHI), to the person(s) or entity listed below.

Patient Name:

Date of Birth:

The records to be released will include (please initial next to only one of the following three options):.

complete medical record including diagnosis and treatment of behavioral and/or mental health conditions, HIV/AIDS, pregnancy, birth control,drug/alcohol use,and/or sexually transmitted infections

fax/email immunization record only

other (specifically describe the information to be disclosed, such as date[s] of services, type of services, medication records, lab results, imaging results)

FROM :

Name: Oak Park Pediatrics

Address: 1107 Chicago Ave

City: Oak Park

State/Zip Code: IL, 60302

Phone: 708-383-2900

TO:

Name:

Address:

City:

State/Zip Code:

Phone:

Release information via:

pick up

mail

email to:

I do not have to sign this authorization in order to receive treatment from Oak Park Pediatrics Ltd. I understand that Oak Park Pediatrics may charge a $15 fee for preparing a mail copy of my record. There is not a charge for emailed records.

Unless revoked in writing, this authorization will expire after 1 year or upon receipt of the requested medical record from Oak Park Pediatrics to whom information is directed to be released.

I understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and no longer be protected by the Health Insurance Portability and Accountability act of 1996. The party authorized to release information, its employees, officers and physicians are hereby released from any legal responsibility for disclosure of the above information to the extent indicated and authorized herein.

Signature of Patient

Date:

Print Name of Patient:

Your information will be encrypted.