Authorization for Disclosure of Protected Health Information

Parent / Guardian Name:*

First NameLast Name

Parent / Guardian E-mail:*

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Patient Name*

First NameLast Name

Patient Date of Birth*

Date

Patient Records to be Disclosed*

Provide Information To:

Name / Company*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

Fax Number

Area CodePhone Number

Email

example@example.com

Delivery Method

FaxEmailPaper Copy in Mail (2-3 week processing time)Other

Important: I understand that unencrypted email is not secure – and therefore may be intercepted by others. I also understand that email may be misdirected and easily forwarded to unintended recipients. By choosing to receive my health information by CD or via email, I am accepting these risks.

Authorization

I hereby authorize Acclaim Autism, its agents and its employees to release protected health information described above. I confirm I am legally authorized to consent for this patient's healthcare. I understand that my authorization will automatically expire one hundred eighty (180) days after the date of signature on this form.

I understand that I may revoke this authorization at any time. I understand that to revoke this authorization, I must do so in writing to Acclaim Autism, 2929 Arch St, Suite 1700, Philadelphia PA 19104. I understand the revocation will not apply to information that has already been released in response to this authorization.

I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by relevant federal and/or state law. If I have requested to receive health information electronically, I acknowledge and accept the risks described above concerning unencrypted electronic formats. My refusal to sign this authorization will not affect any ability to receive treatment.

Authorization*

I hereby authorize Acclaim Autism to disclose the above information. I have read and understand this document. If this form is being signed digitally, I further understand I may submit this request through a paper form by mail or fax if I do not wish to use the digital version.

Date*

Date

Signature*

This form is HIPAA-compliant.

AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION