AUTHORIZATION FOR RELEASE OF INFORMATION

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 Health and Wellness to use and/or disclose certain protected health information about me to the entity listed below.

Patient Name:

Date of Birth:

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

School Name:

Daycare Name:

Other:

This authorization permits Pediatric Health and Wellness to use and/or disclose the following individually identifiable health information about my child (Choose one or more of the following and/or specifically describe the information to be used or disclosed):

Immunization Records

School Excuses

School Forms

Medication Instructions

Medication Authorizations

For the following purpose (please circle one) As requested by:

School Daycare Parent

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

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

Signature of Patient or Legal Guardian:

Patient Name:

Date:

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