AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION: MEDICAL RECORD RELEASE TO PARENT OR GUARDIAN
First & Last Name
Patient Date of Birth
Type YOUR NAME if your are over 18 and requesting for yourself.
To notify you of the completion of your request
I understand that any disclosure of health information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal privacy rules.
I understand that there is a charge for obtaining my child?s records of $0.50/page for the first 50 pages and $0.25/page for all additional pages.
I understand that I have the right to revoke this Authorization at any time, except to the extent action has been taken in response to this authorization, by giving written notice of revocation to the practice at the address noted above. I also understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.
The written revocation must be legible and include the name and date of birth of the individual, the date the revocation is to go into effect, a description of the health information covered by the revocation, the person/entity no longer authorized to the receive the information, the signature of the person with legal authority for authorization/revocation, and if not the individual, a description of their legal authority for authorization/revocation, and their phone number.
I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment, or my eligibility for benefits.
First & Last Name
Unless otherwise revoked in writing, this authorization will expire two years from the signature date.