AUTHORIZATION TO RELEASE MEDICAL INFORMATION

PATIENT INFORMATION

Patient Name:

DOB:

Address:

City:

State:

Zip:

Cell Phone:

RECORDS MAY BE RELEASED FROM:

I authorize

(Healthcare Facility/Physician)

(Phone)

to release information contained in my medical record (including if applicable, information about HIV infection or AIDS, information about substance abuse treatment and information about mental health services).

RECORDS MAY BE RELEASED TO:

Physician/Facility/Other:

Address:

Phone:

Fax:

Please send records via

FaxMailEmail address:

All Records

Last 3 years of records

Well visits only

Lab work only

Specific reports – please specify

Specific dates of treatment

PURPOSE AND NEED FOR SUCH DISCLOSURE:

Attorney/Legal

Insurance

Continued Patient Care

Other (Specify)

I understand that I have the right to revoke this authorization at any time. I understand that if l revoke this authorization, I must do so in writing and present my written revocation to Edgewood Center Pediatrics. We may have already released the information based on your original authorization. We will not release any additional information after we receive your revocation. We will not condition treatment or payment based on this authorization or revocation of this authorization unless otherwise allowed by law. Your protected health information will be disclosed as specified in this authorization. This authorization will expire 120 days from the date of this signature, or when we have completed the disclosure(s) you have requested, whichever is shorter. This information could be subject to re-disclosure by the recipient and may no longer be protected.

Signature of Patient/Parent/Patient Representative

Date

If you are signing as a Parent, Guardian, or Patient Representative, describe this relationship below.

Print Name

Relationship to Patient

*** Fees for Copies: Federal and State Laws permit a fee to be charged for the copying of patient records ***