HIPAA Authorization to Release Medical Records

TO: WADSWORTH PEDIATRICS

Please correct the errors described below.

Patient Info

Release FROM:

Information May Be Sent to Wadsworth Pediatrics via:

Wadsworth Pediatrics

1225 High Street

Wadsworth, OH 44281

Date of Treatment Requested:

Information to be Released (Check all that apply)

Other Information Requested

Acknowledgement

This authorization expires one year from the date of signature,

I understand that my/my child's/my ward's medical record might have information about sexually transmitted disease (STD's), acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It might also have information about mental health problems or services, and/or treatment for alcohol or drug abuse. I understand that if I release my records to someone other than a doctor, insurance company, hospital or other health-related organization, these records may no longer be protected by the Federal privacy regulations, and that this person or organization might release the records to someone else, except as prohibited by 42 CFR Part 2 or other applicable law. I understand that I can revoke or cancel this Authorization at any time, but this foes not apply to records that were already released. If I want to revoke it, I must notify the Privacy Officer, in writing at the institution to which this request was originally submitted.

By signing below, I affirm that I am the patient and/or the patient's personal representative, and have the authority to authorize who may access or receive the patient's health information.

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.

Your information will be encrypted.

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