Release Medical Records to Fairhope Pediatrics

Release Information From

Organization*

Phone*

Fax*

Mailing Address*

City*

State*

Zip*

Release Information To

Fairhope Pediatrics, Inc.

Patient

Patient Name*

DOB*

Patient Address*

City*

State*

Zip*

Release Details

Start Date*

End Date*

Q1*

1. Information authorized for disclosure, if included in my records:

Complete Health Record
Visit/Discharge Summary
Progress Reports
Immunization Records
Radiology/Laboratory/Diagnostic Results
Other

Other*

Q2

2. If applicable, I also give permission for the following “Sensitive Protected Health Information” to be disclosed:

Acquired Immunodeficiency Syndrome (AIDS) or Infection with Human Immunodeficiency Virus (HIV)
Behavioral Health Services/Psychiatric Care
Treatment for Alcohol and/or Drug Abuse
Sexually Transmitted Diseases (STD)
Genetic Counseling/Testing

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*

Q3*

3. The purpose for which disclosure is authorized (check all that apply):

Transition of Care
Personal Use
Legal Purposes
Insurance
Other

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.

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

Name

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

Release Medical Records to Fairhope Pediatrics

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