The following person/organization is hereby authorized to receive my entire medical record, treatment record and diagnostic record from Summit Pediatric Thearpy:
Summit Pediatric Therapy
6851 S Holly Circle, Ste 290, Centennial, CO 80112
Phone: 720-542-8737
Fax: 720-242-8085
By my signature below, I acknowledge that any prior agreement I have made to restrict or limit the disclosure of information about my health does not apply to this authorization.
- Previous Therapy notes
- Patient Histories
- Office Notes (except psychotherapy notes)
- Test Results
- Referrals
- Developmental or other Evaluation reports
- Records Sent by Other Health Care Providers
I understand and agree that health information about me, which is used or disclosed pursuant to this authorization, may be subject to re-disclosure by the recipient and may no longer be protected by law.
This authorization is valid for 24 months following the date of my signature shown below. A copy, electronic copy, image, or facsimile of this authorization is as valid as the original. I have the right to revoke this authorization in writing at any time. I acknowledge that such a revocation is not effective to the extent the above person/organization has relied on the use or disclosure of my health information.
I have read (or have had read to me) this authorization, and I agree to its terms as indicated by my signature below. I am entitled to a copy of this authorization.