AUTHORIZATION TO RELEASE MEDICAL RECORDS

AUTHORIZATION TO RELEASE MEDICAL RECORDS

ADA Pediatrics, P.A. will not receive payment or other remuneration from a 3rd party in exchange for using or disclosingthe PHI. I do not have to sign this authorization in order to receive treatment from Ada Pediatrics, P.A. In fact, I havethe right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, itmay be subject to disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I havethe right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon thisauthorization. My written revocation must be submitted to the Information Privacy Officer at 650 N. Cole Road Boise,Idaho 83704.
I , hereby authorize the transfer of medical records of, blank DOB Date
FROM
Provider Name/Facility
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
TO
Provider Name/Facility
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.

PURPOSE OR NEED FOR DISCLOSURE: (Check applicable categories)
Other

EXPIRATION: This authorization will expire on Date. If I do not indicate a date, this will expire one (1) year from the date of my signature below. A photocopy of this authorization is ascvalid as the original.

SIGNATURE OF PARENT OR GUARDIAN: I understand that this authorization is voluntary. I am confirming my authorization that the health care provider may use and/or disclose to the persons and/or organizations named in this form the protected health information described in this form.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to patient
YOU ARE ENTITLED TO A COPY OF THIS AUTHORIZATION AFTER YOU SIGN IT.
Should be Empty: