• HIPAA Authorization for Use or Disclosure of Health Information

    Carolina Total Child
  • Authorization for Disclosure of Information

    I voluntarily consent to and authorize Johannah Hornak (Provider) to use or disclose my child's health information (excluding session notes) during the term of this Authorization to the recipient(s) that I have identified below.

  • Recipient

    I authorize the release of my child's health information for the following recipient(s):

  • Term

  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  • Clear
  •  -  -
    Pick a Date
  • Parent or Legally Authorized Representative

    In case the subject is beyond the legal age of consent:

  • Clear
  •  -  -
    Pick a Date
  • Should be Empty:
Jotform Logo
Now create your own JotForm - It's free! Create your own JotForm