Authorization for Release of Information To Schools & Daycares

Pediatric & Adolescent Associates

Please correct the errors described below.

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.

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

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

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

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.

Your information will be encrypted.