Records Authorization: To another Provider

Birmingham Pediatric Associates Records Authorization
Patient name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I Name of requester* hereby authorize employees and/or agents of Birmingham Pediatric Associates to use and/or disclose/send protected health information (PHI"):
Address to where records need to be sent.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax number of the receiver of these records
PICK-UP: who will be picking up the information:
First and Last Name
I understand that PHI used and/or disclosed pursuant to this Authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law.
From Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
To Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
1) Specific type of PHI to be used and/or disclosed

Other
Otherblanks
2. The following is the purpose(s) of the use and/or disclosure of my PHI shown above

Other
3. I understand that this Authorization is voluntary, and I have the right to refuse to sign this Authorization. The Practice may not refuse to provide health care treatment to me if I do not sign the Authorization.

4.I understand that upon my request I may see and copy the protected health information described on the Authorization. I understand that my PHI may include information concerning sexually transmitted diseases, behavioral and mental health services, and treatment for drug and alcohol abuse. I understand then I may be charged a reasonable, cost-based fee for uses and disclosures made upon my request.

5. I understand the I may revoke this Authorization in writing, at any time by sending my written revocation to the Privacy Officer at 806 St. Vincent's Drive, Suite 615, Birmingham, AL 35205. I understand that any revocation will not affect any actions taken by the Practice prior to receipt of my revocation.
6. I understand that this Authorization will expire one year from the signature date if an expiration is not provided (such as a date, event, or condition. I elect to have this Authorization expire on:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearNo more than one year from today.
7. I agree to release the Practice, its employees, agents, officers, and directors from any and all liabilities and responsibilities for the use and disclosure of the above information to the extent indicated and authorized pursuant to the signed Authorization.

Name of patient or Personal Representative
Signature
Print Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to patient if not the patient
Best Contact phone number to reach you for questions about this request
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty: