To Schools & Daycares

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

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

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.

Your information will be encrypted.