Person or entity requesting the information and authorized to make the requested use or disclosure:
Facility: Atlanta Pediatric Partners, P.C. Telephone: 4046991339
Continuation of Medical Care This authorization shall remain in effect from the date signed below and for up 90 days thereafter.
I understand that:
- I may inspect or copy the protected health information to be used or disclosed
- I may revoke this authorization in writing by contacting your office at the address above, attention Privacy Officer
- Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by HIPAA
- I may refuse to sign this authorization and that you will not condition treatment or payment on me providing authorization (except to the extent that the authorization is for research-related
- If this line is checked, I understand that you will receive compensation from a third party for the use or disclosure of my information.