Request for Electronic Communications

Name of Patient:

D.O.B.:

Name of Patient:

D.O.B.:

I request that the following information be delivered to me by the provided electronic means. I understand that this form of communication may not be secure, creating a risk of improper disclosure to unauthorized individuals. I am willing to accept that risk and will not hold the practice responsible should such incident occur.

Entire medical record

Medical records for the following dates:

Please provide dates:

For the following purpose:

Please provide purpose:

If transferring records to another primary care physician, please list the reason if any:

Acknowledgement and Agreement: I understand and agree that the requested communication method may not be secure, making my child’s PHI at risk for receipt by unauthorized individuals. I accept the risk and will not retaliate against the practice in any way should this occur.

I also understand that if I am transferring care of my child or children to another healthcare provider, PAA will no longer be available to see my child or children for any appointments or provide instruction from our after-hours call center. If I am eligible to return to PAA, and decide to do so in the future, I understand that I must transfer the entire care of my child or children from the other provider by completing a medical release of information form and requesting the records be sent to PAA.

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

Parent / Guarantor Signature:

Date:

Print Name:

Phone Number:

Email Address:

(We are required by law to provide one free copy of your medical records. Any additional copies will be done at a charge of $1.00 per page)

Your information will be encrypted.