I, the undersigned, am the legal parent/guardian of the above-named minor child, and I authorize the healthcare provider listed below to release and disclose the health information of the minor child as outlined in this consent form.
Healthcare Provider/Organization:
Provider Name/Facility: Wilson Pediatric Therapy
Address: 424 Lewis Hargett Circle, Suite B-100, Lexington, KY 40503
Phone Number: 859-475-4305
Information to Be Released: Medical records, Treatment history and Evaluation reports
Name of Recipient/Organization: Hogg Therapy Pediatrics
Address: 400 Farris Parks Blvd. Richmond, KY 40475
Phone Number: 859-353-3666
Expiration of Consent
This consent will remain in effect until:
Specific date: 1 year from date signed below
Until revoked in writing by me (the parent/guardian).
Revocation:
I understand that I may revoke this authorization at any time by submitting a written request to the healthcare provider. However, revocation will not affect any actions taken before the revocation was received.
Rights of the Parent/Guardian:
I understand that I have the right to inspect or copy the health information to be disclosed under this authorization.
I understand that I am not required to sign this authorization in order to receive treatment, payment, or enrollment in health benefits, unless the disclosure is related to research or a clinical trial.
I understand that any disclosure of health information carries with it the potential for re-disclosure by the recipient and may no longer be protected by federal privacy regulations.
Signature of Parent/Guardian:
By signing below, I acknowledge that I have read and understand the contents of this consent form and I voluntarily give consent for the release of the specified health information.