Release for Patients 18+

Authorization to Disclose Medical Information to Parents/Guardians for Patients 18+ Years

Essex Pediatrics • 89 Main Street, Essex Junction, VT 05452 • (802) 879-6556
Patient Name
Patient Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I give permission to Essex Pediatrics to speak with my parents/guardians and discuss general information from my medical record for the purpose of continuation of treatment.

This permission includes office notes, medication lists, laboratory/radiology reports, problem lists, immunizations, specialty reports, hospital admissions, and emergency room reports.

The following medical records have special protections. I give my specific permission to discuss the records that are selected and initialed below.
I give permission to share mental health records
Initials
I give permission to share HIV/AIDS records
Initials
I give permission to share alcohol/drug treatment records
Initials
I give permission to share sexual abuse/assault and domestic violence records
Initials
I give permission to share sexually-transmitted infection records
Initials
Parent/Guardian 1 Name

First NameLast Name
Parent/Guardian 1 Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 1 Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 2 Name

First NameLast Name
Parent/Guardian 2 Primary Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian 2 Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
I understand that:
- The recipient authorized to receive my information may not be required to protect my information and may share my records without my permission.
- Signing this form is voluntary. I do not need to sign this form to receive health care services at Essex Pediatrics.
- I may cancel this authorization at any time by providing written notice to Privacy Officers, Sue Rogers-Low or Jill Kenneson at 89 Main St, Essex Junction, Vermont, 05452. My revocation will not apply to the information that has already been released in response to this authorization.
- I may inspect or copy any information to be used or disclosed under this authorization.
- Unless otherwise cancelled in writing, this authorization will automatically expire one year from the date I sign below.
Patient Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Authorization to Disclose Medical Information to Parents/Guardians for Patients 18+ Years