Secure Authorization for Disclosure of Clinical Information
Pediatrics at Newton Wellesley, P.C.
Please correct the errors described below.
I authorize Pediatrics at Newton Wellesley, P.C. to communicate with the following providers, as needed, to help with evaluation, treatment planning and coordination of care:
Pediatrics at Newton Wellesley, P.C. has my permission to release information/records acquired in the course of ongoing mental health assessment, evaluation and/or treatment of the above named patient, including telephone contact and email.
*HIV and Substance Abuse information is protected under federal law and must be authorized specifically in order to be use/disclosed.
This authorization will expire with the completion of treatment, unless otherwise changed and/or revoke.
I understand that I may revoke this consent at any time, and that I must notify Pediatrics at Newton Wellesley, P.C. in writing. I understand that such a revocation does not affect any action taken by Pediatrics at Newton Wellesley, P.C. prior to receiving my written notice.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.