SECURE EMAIL AUTHORIZATION

SECURE EMAIL AUTHORIZATION

Pediatric Development Center of Atlanta, LLC

3200 Highlands Pkwy SE Ste 150

Smyrna, GA 30082

770-433-2300

Your Name *

First Name Last Name

Your Child's Legal Name *

First Name Last Name

Child's Date of Birth *

Relationship to Child *

HIPAA Office Secure (Encrypted and Password Protected) Email System *

On behalf of my child (Legal Name listed above), I authorize Pediatric Development Center of Atlanta, LLC, to deliver copies of written Documents, including but not limited to Evaluation Reports, Plans of Care Reports and other information related to the treatment of my child, utilizing their HIPAA Office or MDOfficeMail Secure Email Systems (Encrypted and Password Protected) to my active email address listed below.

My active email address is: *

You, the parent, may revoke this authorization at any time by executing a written revocation, subject to the right of any person who acted in reliance on the authorization prior to receiving notice of revocation.

You, the parent, must deliver the revocation of your authorization to us by hand, certified mail or by express delivery service.

You, the parent, agree to notify us immediately of any changes to your email address.

You are entitled to a copy of this authorization.

Signature of Parent *

Clear

Date *

Date