Authorization to Release Patient Health Information

Authorization to Release Patient Health Information
Patient Name:*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
I authorize the following organization to release information as stated below from the patient health information record:
Information to be released from:*
Information to be released to:*
Information to be released to:*
Organization/Person Name:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email*
example@example.com
Information to be released to: 

Allegro Pediatrics
2475 NE 140th ST
Bellevue, WA, 98005
Fax: (425)-460-3374
Do you have an upcoming appointment with this organization?

YesNo
Last well care, growth charts, immunizations, summary report, and medication history will be faxed ahead of your appointment.
Date of Upcoming Appointment:

MonthDayYear
Date
I authorize ongoing communication between the parties above.
Information to be Released
Entire RecordMoving Packet (Last well care, growth charts, immunizations, summary report, and medication history)Other
Please Specify: *
Records will be sent by:*

FaxSecure Email (To access records you will need patients full name and date of birth.)Secure USB StickMail
All records will be sent via secure USB stick. Paper records can be sent but can take up to 30 business days.

I do not want my records sent via secure USB stick and would prefer paper
All records will be sent via secure email link. Paper records can be sent but can take up to 30 business days.

I do not want my records sent via secure USB stick and would prefer paper
**Please Note: Sending paper records can take up to 30 business days**
Purpose of Release:*

Transfer to another providerLegalPersonal useContinuing care/specialistSchoolOther
Is there a court case involved?

YesNo
Date of court case:

MonthDayYear
Date
Reason:
Type of Specialist:
Authorization for General Release of Information
I understand that:
- Authorizing the disclosure of this healthcare information is voluntary. I do not need to sign this form in order to assure treatment or payment.
- I can cancel this authorization at any time by written notification to Allegro Pediatrics. I understand that once the information has been released according to the terms of this authorization, the information cannot be recalled.
- Any disclosure of information carries with it the potential for further releases or distribution by the recipient that may not be protected by confidentiality laws.
This authorization will expire 90 days from the date signed below or until it's revoked in writing by the individual, whichever comes first. (Note: If the disclosure is to another employer or financial institution, this authorization will expire 90 days from the date signed by you.)
Sensitive Records may require specific patient authorization, please check the applicable box below to withhold any the following records:

Drug/Alcohol Abuse/Treatment & DiagnosisSexually Transmitted DiseasesMental Health TreatmentHIV/AIDS Diagnosis/Treatment/TestingReproductive Health Care
**With sensitive information being requested, your records will be sent via paper**
Signature of Minor Patient Required for the Following Records (Ages 13-17)

A minor patient’s signature is required to release the following information: 1) Information related to reproductive care such as birth control, pregnancy-related services (all ages) 2) Sexually Transmitted Diseases, including HIV/AIDS (age 14 and older); 3) Substance abuse and mental health treatment (age 13 and older).
Signature of Minor Patient:

Clear
Today's Date:*

MonthDayYear
Date
Signature of Patient (18 years or older) or Legally Responsible Party:

Clear
Relationship to Patient:
Today's Date:*

MonthDayYear
Date
Should be Empty:

Authorization to Release Patient Health Information

Information to be Released

Authorization for General Release of Information

Signature of Minor Patient Required for the Following Records (Ages 13-17)