SECURE EMAIL AUTHORIZATION

SECURE EMAIL AUTHORIZATION

Pediatric Development Center of Atlanta, LLC

1031 Trippe Cir

Greensboro, GA 30642

404-617-7672

Your Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

Your Child's Legal Name*

First NameLast Name

Child's Date of Birth*

Relationship to Child*

MDOfficeMail 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 MDOfficeMail Secure Email System (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, mailing address, and telephone number.

You are entitled to a copy of this authorization.

Signature of Parent*

Clear

Date*

Date