Add an authorized representative

Please list anyone (other than parent(s) or legal guardian(s) authorized to be your representative and bring your child(ren) to appointments:

I understand that I can change or revoke the below authorization at any time but I can't change or revoke names given by another parent.

CONDITIONS OF AUTHORIZATION

I have the right to revoke this authorization at any time by writing to the Privacy Officer at All Star Pediatrics at the above address and revoking my permission. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. I understand that signing this form is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure. Information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by Federal or State privacy regulations.