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.
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