AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION (FROM)

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

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

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.

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

OFFICE USE ONLY

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