18 & Over - HIPAA Release and Consent Form

18 & Over - HIPAA Release and Consent Form
Patient Name*

First NameLast Name
Date Of Birth*

MonthDayYear
Date
Your phone number
Please enter a valid phone number. By providing my contact information, I acknowledge and give my explicit consent to be contacted via SMS. Message and data rates may apply. Message frequency may vary. Reply STOP to opt out
I understand and acknowledge that as of my 18th birthday, my parents and/or guardians will no longer be permitted access to my medical records, information, providers, or appointment status without my specific written permission. Ball Pediatrics will not speak with my parents, permit my parents to schedule appointments, or release medical information to my parents without my written consent in accordance with this document.

This document is valid until I request changes and any changes to this document must be in writting.
I DO NOT grant any access to my parents and/or guardians. No medical information, records, lab results, or appointment information can be discussed or released
I WISH TO grant my parents and/or guardian access to my healthcare providers and/or medical information as follows:
Parent/guardian 1

First NameLast Name
Parent/guardian 2

First NameLast Name
Parent/guardian 3

First NameLast Name

	All information/no restrictions	Only visit notes	All Lab Results	All labs except pregnancy test/STI testing	Vaccine information
Parent/guardian 1
Parent/guardian 2
Parent/guardian 3