Release Medical Records from Fairhope Pediatrics

Release Information From

Fairhope Pediatrics, Inc.

Release Information To

Organization*

Phone*

Fax*

Patient

Patient Name*

DOB*

Release Details

Start Date*

End Date*

Other*

I understand that the information disclosed pursuant to this Authorization, except information protected by Federal and/or State regulations about confidentiality of drug and alcohol abuse records, HIV and Mental Health, may be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations or other applicable state and federal laws.

Initials*

Other*

4. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the provider(s) of care. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to review or contest a claim. Unless otherwise revoked, this authorization will expire on the following date, event, or condition:

Expiration Date*

If I fail to specify an expiration date, event, or condition, this authorization will expire in 90 days.

5. I understand that any disclosure of healthcare information carries with it the potential for unauthorized and future re-disclosures, as allowed by HIPAA and other federal privacy rules. If I have questions about disclosures of my health information, I can contact my provider of care.

6. This facility, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.

Why are you requesting your child’s records?*

Records - Other*

Please tell us why you are transferring to another pediatrician or other primary care provider.*

Transfer - Other*

Authorization

By signing this Authorization, I authorize my Health Care Provider to disclose my protected health information.

Parent/Guardian Name*

Relationship*

Parent/Guardian Signature*

Hidden

Date

Email

This field is for validation purposes and should be left unchanged.

Release Medical Records from Fairhope Pediatrics

Release Information From

Release Information To

Patient

Release Details

Authorization

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