Release of Health Information Authorization - Form B

I, or my authorized representative, request that health information regarding my care and treatment be RELEASED as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

I understand that:

1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I mark the appropriate box listed below. In the event the health information described below includes any of these types of information, and I mark the box below, I specifically authorize release of such information to the person(s) indicated in Item 7.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this re-disclosure may no longer be protected by federal or state law.
6. Name and address of health provider or entity to RELEASE this information:

7. Name and address of health provider or entity to RECEIVE this information:

SUMMERWOOD PEDIATRICS

4811 BUCKLEY ROAD

LIVERPOOL, NEW YORK 13088

PH: 315-457-9966 FAX: 315-457-9854

The information to be disclosed from my health record: (Check appropriate box/boxes. Only the selected information will be released)

Medical record requests could take up to 2 weeks to be processed.

• I understand that my medical and/or billing information may be re-disclosed and no longer protected by federal health information privacy regulations if the recipient described on this form is not required by law to protect the privacy of your information.
• I understand and am aware of security risks associated with unsecured transmission of my Personal Health Information (PHI) by fax. I accept this security risk and request to have my PHI sent by the method indicated above.
• I understand that I have the right to inspect and/or receive a copy of the information described on this authorization form by completing a request for access form.
• I understand I have the right to receive a copy of this authorization form after I have signed it.
• I understand I may revoke this authorization, in writing, at any time.
• This authorization will terminate ONE YEAR from the date of my signature.

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.