HIPAA RELEASE FOR ADDITION OF MINOR

HIPAA Release for Rx365 Mobile Application (Minors)

Information collected on this form will be used to document authorization for personal health information to be released through the Rx365 mobile application for minors.
Please confirm: you are authorizing the release of health information for a person or person(s)...

Under the age of 18 years18 years of age or older
We are sorry!

This form is to be used for people under 18 years of age! If you are medical power of attorney or have guardianship over an adult person over the age of 18 and would like to add them to your profile, please reach out to us at (715) 453-6600
Parent or Legal Guardian's Name
Phone
Rx365 Email Address
example@example.com
Address

Address

Street Address Line 2

City StateState / Province

Zip

Terms & Conditions

By signing below, I confirm I am the parent or legal guardian of the above-mentioned minor(s). I understand that upon the minor turning 18 years of age, my access to their protected health information will be automatically revoked from the Rx365 mobile application. In order to recover this information, consent will need to be provided to re-release.
Parent or Legan Guardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

HIPAA Release for Rx365 Mobile Application (Minors)