Authorization For Use And Disclosure Of Protected Health Information Form

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15293 Amberly Drive
Tampa, Florida 33647
(813) 631-1100
Authorization for Use and Disclosure of Protected Health Information
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information
about your child. The Notice contains a Patient Rights section describing your rights under the law. You have the right
to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you
may obtain a revised copy by contacting our office.
You have the right to request that we restrict how protected health information about your child is used or disclosed
for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do,
we shall honor that agreement.
By signing this form, you consent to our use and disclosure of protected health information about your child for
treatment, payment, and health care operations. You have the right to revoke this Consent, in writing, signed by you.
However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The
Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
It is understood that:
•
Protected health information may be disclosed or used for treatment, payment, or health care
operations.
•
The Practice has a Notice of Privacy Practices and you have had the opportunity to review this
Notice.
•
The Practice reserves the right to change the Notice of Privacy Policies.
•
The patient’s legal representative has the right to restrict the uses of information but the
Practice does not have to agree to those restrictions.
•
The patient’s legal representative may revoke this Consent in writing at any time and all future
disclosures will then cease.
•
The Practice may condition treatment upon the execution of this Consent.
Other than described above, individual to whom information may be given regarding your child’s medical records:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Print Name of Patient _____________________________________________________________________
Signature _____________________________________________________
Date ___________________
Relationship _____________________________________________________________________________
Witness ______________________________________________________
Date ___________________
HIPAA

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