Hipaa Records Release - Greenwich Pediatrics (Page 2 of 3) in pdf

Hipaa Records Release - Greenwich Pediatrics Page 2

RELEASE/SEND TO:

__________________________________________________

FAMILY NAME: _______________________________________________

(Date of Birth)

(Signature*)

Child(s) Name: ____________________ ____________ _____________________________

_____________________ ____________ _____________________________

This authorization is valid unless and until it is revoked, in writing, and properly presented to the

records office of the provider listed above.

I understand that if the person or the entity that receives the information is not a health care

provider or health plan covered by the federal privacy regulations, the information described

above may be re-disclosed and no longer protected by those regulations.

I understand that I may refuse to sign this authorization and that my refusal to sign will not affect

my ability to obtain treatment or payment or my eligibility for benefits. I may inspect or copy

any information used/disclosed under this authorization.

I understand that I may revoke this authorization in writing at any time by submitting a written

notice of my revocation, except to the extent that action has been taken in reliance on this

authorization.

The authorization expires ___________________________.

Signature: ___________________________________

Print Name: ________________________

(Parent or guardian if a minor, please specify relationship to patient)

Please note that a child 13 yrs old or older must sign permission for records release)

If a representative signs, describe the representative’s authority to act on

behalf of the patient:

Hipaa Records Release - Greenwich Pediatrics Page 2