Please correct the errors described below.

The information may be released by:

The Information may be released to:

I understand the information released will be limited to information necessary to fulfill the need or purpose for the disclosure. If I have authorized the disclosure of information to a recipient who is not subject to the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), then the recipient may re-disclose the information and it may no longer be protected under HIPAA, a federal privacy law. This authorization is valid for ninety (90) days from the date signed unless otherwise noted. This Authorization only applies to treatment occurring before the date of signature. I may decline to sign this Authorization. I understand that I may revoke this authorization in writing at any time by completing a form available from Redmont Pediatric Associates, Pc. If I revoke this authorization, the revocation will not apply to information that has already been released in response to this authorization. I understand the patient's health care and payment for the patient's health care will not be accepted if I do not sign this form. I understand I may see and copy the information described on this form if I ask Cor it and I may receive a copy of this form after I sign it. I may be charged reasonable copy fees as indicated under state law for my request. I represent that I have the authority and voluntarily grant permission for the information to be released as described above.

Phone Numbers:

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.

(if under age 14 must be signed by parent or guardian)
(patient age 14 and up)

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