Hipaa Records Release - Greenwich Pediatrics printable pdf download

Hipaa Records Release - Greenwich Pediatrics

GREENWICH PEDIATRIC ASSOCIATES, LLC.

HIPAA AUTHORIZATION FOR RELEASE OF PATIENT RECORDS

I hereby authorize Greenwich Pediatric Associates to release my medical health records

including a copy of my complete and entire mental health record, all records for my care and

treatment, including psychiatric and drug information, and information regarding HIV/AIDs

status, treatment or testing, emergency room records, nursing notes, laboratory results

(individually copied), pathology reports, x-ray reports.

If any of the information to be released constitutes a psychiatric communication or a

communication with a psychologist, this release will serve as my written release of that

information.

I understand that I may refuse to grant the consent for this release of

psychiatric/psychological information, and such a refusal will in no way jeopardize my right to

continue to obtain treatment, unless disclosure is otherwise permitted by law or necessary for

treatment.

I understand that no psychotherapy notes may be disclosed by my signing this authorization and

that a separate authorization would be required for the release of psychotherapy notes.

If any of the information to be released relates to treatment for alcohol and drug abuse, I

understand that there are special requirements for my consent to release as found in Part 2 of

Title 42 of the Code of Federal Regulations, which prohibits the further release of that

information without my consent, as referenced in the federal regulations, or as otherwise

permitted by law.

The information to be used/disclosed consists of:

Note: This description must be specific and meaningful. If all records are being authorized for

release, “entire record” should be stated.

The information will be used/disclosed for the following purposes:

Please circle reason for transfer: Relocation / To “Adult Physician” /

Change of Insurance (which?________)

Other (please explain): ____________________________________________

Hipaa Records Release - Greenwich Pediatrics