AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION (FROM)

Patient Name:

Date of Birth:

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Current Phone Number

I hereby authorize the disclosure of health information for the person(s) listed above.

From:

Complete mailing address required

To: The Pediatric Center, PPLC
4745 Arapahoe Ave., Suite 310
Boulder, CO 80303

REASON FOR THIS AUTHORIZATION (check all that apply)

at my request

other

If other, please specify:

PLEASE RELEASE THE FOLLOWING INFORMATION:

Immunization Records only

Most Recent Physical Exam only

Complete Clinical Records Produced in this Office only

Complete Clinical Records Produced in this Office and Those Transferred to us from outside providers

I understand that the information in my health record may include information relating to sexually transmitted disease, or acquired immunodeficiency syndrome (AIDS). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse.

MY RIGHTS

I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment or enrollment).

I may revoke this authorization in writing. If I do, it will not affect any actions already taken by the above named practice based upon this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance.

REDISCLOSURE

I understand that once the office discloses health information, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.

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.

Patient or legally authorized individual name:

Date:

Printed Name if signed on behalf of the patient:

Relationship (parent, legal guardian, etc.):

This authorization is valid for 90 DAYS from the date of signature.
A COPY OF THE REQUESTING PERSON’S PICTURE ID IS REQUIRED.

PLEASE INDICATE IF YOU ARE TRANSFERRING CARE

Yes No

If so, for what reason

Moving from area

Insurance change

Child too old to see a Pediatrician

Dissatisfaction

If "Dissatisfaction" is selected, please explain:

OFFICE USE ONLY

ID checked:

Initials:

Date:

Your information will be encrypted.