Authorization to Release/Exchange Information

I, the parent or legal guardian of the below named patient, authorize Tri-State Developmental Pediatrics to share the following private health information pertaining to my child (check all that apply):

Permission is granted to exchange/release information with:

Primary Care Provider

School Personnel: School Teachers/ Principal/ School Psychologist and IEP/504 support team

Therapist/Counselor

Permission to release the following information:

Medications

Medical Evaluation/Reports

Email/Fax/Phone Communication

This consent will automatically expire one (1) year after the date of my signature as it appears below, or on the following earlier date, condition.
I understand I have the right to refuse to sign this form, and that I may revoke my consent at any time (except to the extent that the information has already been released).

Parent of Guardian NameEmail addressPatient NamePatient Date of BirthInitialsBy typing my initials, I acknowledge and give my consent to exchange medical information with the above named parties

Parent or Guardian Name

Email address

PCP Name AND Practice

Patient Name

Patient Date of Birth

By typing my initials below, I indicate that I am granting permission for Tri-State Developmental Pediatrics to share my child's personal health information to the parties indicated above.

Date

Your information will be encrypted.