I allow SAUGATUCK PEDIATRICS LLC at 191 Post Road West, Westport, CT 06880, to access my child’s patient records via *Clinical Document Exchange, a secure method of electronically obtaining medical information from different healthcare organizations (i.e. hospital or specialist) for treatment purposes only.

• 
  I understand that I may revoke this authorization at any time by notifying the providing organization in writing, and it will be effective on the date notified except to the extent action has already been taken in reliance upon it. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by Federal privacy regulations.
  
   
  *What is Clinical Document Exchange?
  Clinical Document Exchange allows different healthcare organizations to exchange patient records. Your participation allows other providers you see to obtain your patient records for treatment purposes.
  For example, your child is seen by a specialist or in the Emergency Room at another hospital. That provider can quickly access your child’s records to find out what medications your child is taking, or that they have a medication allergy.
  How much of my data is being shared?
  Your most up-to-date Summary of Care record is made available and contains information including:
• Demographic data (name, date of birth, address)
• Clinical data
  Diagnoses
  Allergies
  Medications
  History of Procedures
  Diagnostic and Laboratory Test Results
  History of Immunizations
• Insurance Policies 

Who has access to my data?
Only providers at healthcare organizations that participate in Clinical Document Exchange through the interoperability framework Carequality are able to retrieve your records. They may retrieve your records for treatment purposes ​only.​
How is my data secured?
In accordance with industry standards many layers of security, including encryption, protect patient data when it is transmitted to a different healthcare organization.