• Authorization to Share Medical Information with Another Party

    Essex Pediatrics • 89 Main Street, Essex Junction, VT 05452 • (802) 879-6556
  • Patient Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • I give Essex Pediatrics permission to share with another party general information from the patient’s medical record for the purpose of continuation of care.

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

    The following medical records have special protections. I give specific permission to share the records that are selected below.

  • I give permission to share mental health records.*
  • I give permission to share HIV/AIDS and sexually transmitted infection records.*
  • I give permission to share alcohol/drug treatment records.*
  • I give permission to share sexual abuse/assault and domestic violence records.*

  • Patient/Parent/Guardian 1

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Patient/Parent/Guardian 2

  • Format: (000) 000-0000.

  • Medical Information To Be Sent To:

  • Format: (000) 000-0000.

  • Authorization

  • I understand that:

    • I may cancel this authorization at any time by providing written notice to Privacy Officers, Sue Rogers-Low or Jill Kenneson at 89 Main Street, Essex Junction, VT, 05452.
    • My revocation will not apply to the information that has already been released in response to this authorization.
    • Unless cancelled in writing, this authorization will automatically expire one year from the date I sign below.
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: