PANF Release of Information Form

Patient Name*

Date of birth*

Date

Types of Information to be Shared*

Entire treatment recordCurrent status and locationBilling statementsOther

Purpose of Disclosure*

Continuity of careEmergency managementAccount managementOther

Person or Organization with Whom Information can be Shared*

Title of Person or Organization with Whom Infomrmation can be Shared (i.e. teacher, lawyer, psychiatrist, etc.)*

PHONE*

FAX NUMBER

EMAIL

example@example.com

For dates starting:*

Date

And ending*

Until care is terminatedEnter date below

Through:

Date

Duration and Revocation of Authorization

I understand that I can revoke this authorization at any time prior to the provided date by contacting the practice in writing.

I understand that if the practice has already shared the information authorized here at the time I revoke this authorization, then it is too late to prevent that information from being shared.

I understand that the practice cannot make completion of this authorization a condition for any treatments or benefits I am entitled to, unless this authorization is necessary to determine eligibility for treatment or benefits or to pay for treatments I receive.

I hereby authorize PEDIATRIC ASSOCIATES OF NORWOOD AND FRANKLIN to release information as described above to, and request information from, the person or organization identified herein. I understand that the person or organization named above may not be subject to the same privacy laws and regulations as Norwood Behavioral Health and may be able to further share the information disclosed under this authorization. I consent to use electronic signatures, and my signature below is the same as a handwritten signature for the purposes of validity, enforceability, and admissibility.

Client/Parent/Guardian signature:*

Print name*

Date*

Date