AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION FORM

Please correct the errors described below.

***PLEASE PROVIDE PREVIOUS DOCTOR’S INFORMATION BELOW***

TO DISCLOSE TO:

SUNNIE SKILES, M.D. PEDIATRIC HEALTH & WELLNESS 6815 FIVE STAR BLVD. #100 ROCKLIN, CA 95677 PHONE: 916-626-3060 FAX: 916-626-3063

VACCINE RECORDS COMPLETE MEDICAL RECORD

MY RIGHTS: I may refuse to sign this authorization. My refusal will not affect my ability to obtain treatment, payment, or eligibility for benefits. I may revoke this authorization at any time, but I must do so in writing and submit it to the following: Attn: Privacy Official 6815 Five Star Blvd #100, Rocklin, CA 95677. My revocation will take effect upon receipt, except to the extent that others have acted in reliance upon this authorization. I have a right to receive a copy of this authorization. Information disclosed pursuant to this authorization could be re-disclosed by the recipient. Such re-disclosure is in some cases not protected by California law and may no longer be protected by federal confidentiality las (HIPAA). If this authorization is for the disclosure of substance abuse information, the recipient may be prohibited from disclosing the information under 42 C.F.R part 2.

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.

Note: If the substance abuse treatment information is protected by federal confidentiality rules (42 C.F.R. part 2) the following prohibition of re-disclosure statements must be provided to the recipient of the information: The federal rules prohibit the recipient from making any further disclosure of the information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted by 42 C.F.R. part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

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