HIPAA Release for Patients 18 and Older

HIPAA Release for Patients 18 and Older
Without my specific written permission, I understand that as of my 18th birthday, my parents and/or guardian are no longer permitted to access my medical records, receive information regarding my healthcare, contact my providers on my behalf, access my portal account, or inquire about my appointment status.

I would like to authorize my parent and/or guardian to have complete electronic access to my medical information via my patient portal. I understand this authorization will also grant access via traditional forms of communication, including, but not limited to, telephone.
Yes No
18 Years and Older HIPAA Release and Authorization for Parent/Guardian Portal Access
I understand and acknowledge that as of my 18th birthday, my parents and/or guardian are no longer permitted to access my medical records, receive information regarding my healthcare, contact my providers on my behalf, access my portal account, or inquire about my appointment status without my specific written permission. Allegro Pediatrics will not release any medical information to my parents and/or guardian without my written authorization in accordance with this document.

By authorizing this HIPAA release, my parent and/or guardian will have electronic access to my medical information via my patient portal, as well as access via traditional forms of communication, including, but not limited to, telephone. My medical information includes, but is not limited to, the following:

• My diagnoses

• My medications

• My immunization records

• My orders and results

• My patient instructions and education

• This includes sensitive information, including, but not limited to,

o Drug/alcohol abuse diagnosis and treatment

o Sexually transmitted infection screening, diagnosis, and treatment

o Mental health diagnosis and treatment

o HIV/AIDS screening, diagnosis, and treatment

o Reproductive health care

In addition, my parent and/or guardian, on my behalf, will be able to:

• Request medical records

• Make an appointment

• Request medication refills

• Ask for nurse advice

• Ask additional questions

I understand that messages sent solely between me and Allegro Pediatrics via my personal portal access account are the only items that remain private.

I understand disclosing my healthcare information is voluntary. I understand that once the information is disclosed it may be re-disclosed by the recipient and may no longer be protected by federal or state privacy regulations.

I give the individuals(s) named below permission to act on my behalf with no limitations, I understand that they may contact any provider or staff member to discuss my healthcare and access my complete medical record; there are no restrictions. If I want to revoke this authorization, I must do so in writing to Allegro Pediatrics at 2475 140th Ave NE, Bellevue, WA, 98005 or at an office via a revocation form.
Parent/Guardian 1
Name:

First Name Last Name
Date of Birth:

Month Day Year
Date
Sex:
Email:
example@example.com
Phone Number:
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Relationship to Patient:
Parent/Guardian 2
Name:

First Name Last Name
Date of Birth:

Month Day Year
Date
Sex:
Email:
example@example.com
Phone Number:
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Relationship to Patient:
By signing your name into the box below, you are declaring under penalty of perjury under state and federal laws that you are the patient or court-appointed legal guardian of this 18 years or older patient and are therefore authorized to provide this HIPAA release. Furthermore, you acknowledge that this HIPAA release will remain in effect until you notify us in writing.
Patient Name:

First Name Last Name
Signature:

Clear
Date:

Month Day Year
Date
Should be Empty:

HIPAA Release for Patients 18 and Older

18 Years and Older HIPAA Release and Authorization for Parent/Guardian Portal Access

Parent/Guardian 1

Parent/Guardian 2