RECORDS RELEASE AUTHORIZATION (OUTGOING PATIENTS)

I AUTHORIZE REIS PEDIATRICS TO RELEASE PROTECTED HEALTH INFORMATION TO:

Name of Healthcare Provider

Address:

Telephone Number:

Fax Number:

Please select:

All Healthcare Information

Immunization Record Only

Lab Report(s)

Date(s)

Consultation Note(s)

Date(s)

For the following patients:

Child name:

Date of Birth:

Add more children

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.

Parent’s name:

Address:

Phone number:

Reason for leaving Reis Pediatrics:

Signature

Date:

This Authorization will expire 90 days after the date identified above. You can cancel this authorization at any time, but you must do so in writing. If you cancel it, the people authorized to use and disclose your protected health information may use the information collected prior to the date you revoked this authorization. Please send written revocation to the individual or department who you authorized to use your protected health information. Also, please be aware that once we disclose this information per your instructions, the information is subject to re-disclosure andmay no longer be protected.

Office Use Only

Outstanding Patient Balance:

Outstanding Insurance Balance

Date Payment Collected:

Payment Type:

CA CC CK

Date Faxed:

Your information will be encrypted.