Authorization For Release Of Medical Records

Starlight Pediatrics | Dr. Maria Castro | Phone:919-762-5113 | Fax:919-762-5130

Please correct the errors described below.

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  1. Unless otherwise revoked, this authorization will expire in one (1) year from the day of the signature.
  2. I understand that I may revoke this authorization (except to the extent that action was already taken in reliance on this signed authorization) at any time by notifying Starlight Pediatrics in writing.
  3. I understand that I can refuse to sign this authorization and that my refusal will not affect my child/children’s ability to obtain treatment, or to process payments.
  4. I may inspect or copy any information used or disclosed under this agreement.
  5. I understand that if the person or organization that receives the information is not a health care provider or plan covered by federal privacy regulations, the information described above may be redisclosed and would no longer be protected by these regulations.

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