PHI Release

Patient's Name*

First NameLast Name

Date of Birth*

Date

Gender*

MaleFemaleOther

Provider Name and/or Practice Name*

Street Address*

Suite/Unit*

City*

State*

Zip Code*

Fax Number*

Phone Number*

Email (if applicable)*

example@example.com

FaxMailEmail

This consent is valid for this date range:*

Start Date

End Date

Alcohol/Drug Use TreatmentTreatment for Behavioral HealthTreatment for Sexually Transmitted Infections/DiseasesTreatment for HIV/AIDS

I understand and agree that: Pedi-Q Urgent Care cannot control how the recipient uses or shares the information, and that laws protecting its confidentiality at Pedi-Q Urgent Care may or may not protect this information once it has been released to the recipient. This authorization is voluntary. My/my child's treatment, payment, health plan enrollment, or eligibility for benefits will not be affected if I do not sign this form. I may cancel this authorization at any time by submitting a written request to Pedi-Q Urgent Care, except: if Pedi-Q Urgent Care has already relied upon it (the information has already been released) and/or if I signed this authorization as a condition of obtaining insurance, other laws may provide the insurer with a right to contest a claim under the policy or the policy itself. This authorization will automatically expire 6 months from the date signed unless otherwise specified. My questions about this authorization have been answered.

ParentGuardian Signature*

Relationship to Patient*

Patient/Parent/Guardian Name*

Date*

Date

Authorization to Release Protected Health Information

Patient Information

Requesting Provider

Purpose of Release

Method of Release

Information to be Released

Information That You Authorize to Release

Sensitive Information Authorization

Patient/Parent/Guardian Statement of Consent