Minor Disclosure

Please fill out this form as completely as possible. It will be sent securely to our office.

MEDICAL INFORMATION DISCLOSURE FOR MINORS 14 AND OLDER

Patient
Patient Name*
DOB*
Mobile Phone
Email
Release Details
Q1*
I understand as a patient age 14 or older that my medical information will no longer automatically be shared with my parents/legal guardians. I hereby authorize Fairhope Pediatrics, Inc., its representatives, physicians, and staff, to share non sensitive medical and financial information with the following individual(s).
- At this time I do not give authorization for my medical information to be discussed with anyone other than myself.
- I give authorization to the providers and staff at Fairhope Pediatrics, Inc., to discuss my medical information with the following individuals:
Name1
Relationship1
Phone1
Name2
Relationship2
Phone2
Name3
Relationship3
Phone3
Q2*
If applicable, I also give permission for the following “Sensitive Protected Health Information” which includes mental health, substance abuse, sexual health, sexually transmitted diseases/AIDS/HIV testing and results.
- At this time I do not give authorization for any “Sensitive Protected Health Information” to be discussed with anyone other than myself.
- I give authorization to the providers and staff at Fairhope Pediatrics, Inc., to discuss any “Sensitive Protected Health Information” with the following individuals:
Name4
Relationship4
Phone4
Name5
Relationship5
Phone5
Name6
Relationship6
Phone6
Signature
I fully understand and accept the terms of this consent. I understand that I may revoke this consent at any time, and that I must notify Fairhope Pediatrics, Inc., in writing.
Patient Signature*
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Date
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Email
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Minor Disclosure

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