Authorization for Release of Information To Schools & Daycares

Must be completed for all authorizations

I hereby authorize the use or disclosure of my health information as described below. By signing this authorization, I authorize Pediatric & Adolescent Associates to use and/or disclose certain protected health information (PHI) about me to the entity listed below.

Patient Name:

D.O.B.:

Patient Name:

D.O.B.:

Patient Name:

D.O.B.:

Patient Name:

D.O.B.:

Organization/Persons receiving the information: (Please list name and address.)

School Name:

Daycare Name:

Other:

This authorization permits Pediatric & Adolescent Associates to use and/or disclose the following individually identifiable health information about me.

Please check one or more of the following:

Immunzation Certificates

School Excuses

School Forms

Medication Instructions

Please specifically describe the information to be used or disclosed.

For the following purpose: As requested by school. daycare, or parent via mail. phone or fax.

I do not have to sign this authorization in order to receive treatment from Pediatric & Adolescent Associates. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted to the Privacy Officer at 3050 Harrodsburg Road, Lexington, KY 40503.

I do not authorize the release of health information to schools or daycares.

I understand that this authorization is valid for 1 year from date signed, unless revoked in writing.

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.

Signature of Patient or Legal Guardian:

Print Name:

Date

Relationship to the Patient:

Your information will be encrypted.