Release of Records TO Ideal Pediatrics
First and last.
Name of facility to provide medical information TO Ideal Pediatrics
(if you know it)
mm/dd/yyyy-mm/dd/yyyy or ALL DOS
I understand that the information in my health record may include information relating to communicable disease, Acquired
Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV), behavioral or mental health, alcohol/drug
(substance) abuse or any such related information.
This information may be disclosed to and used by the following individual or organization (receiving the information)
Ideal Pediatrcs- ph. 618-281-4325- 1550 N Main St, Columbia, IL 62236- f. 618-281-8393
I understand that this authorization is voluntary and I may refuse to sign this authorization. I further understand that my health care and the payment of my health care will not be affected if I do not sign this form. I may inspect or copy the information to be used or disclosed, and that information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient, and may
no longer be protected by federal and state privacy regulations. The Clinic may charge a processing fee for this service. This
authorization will expire by law 180 days from the date of this authorization unless I otherwise specify.
I further understand that I may revoke this authorization at any time by notifying the Health Information Management Department of Ideal Pediatrics,. If I revoke this authorization I must do so in writing and the written revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any actions taken before the receipt of the written revocation.