Release of Information

Release of Information
AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION. I authorize the release of my child's medical records to and from Julie Abrams, OTR, LLC and Amanda Betzen, OTR, LLC to…
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    AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION

1.      Please release health information related to Occupational Therapy and Educational records/information

2.      Once information is disclosed pursuant to this signed authorization, I understand that the federal privacy law (45 C.F.R. parts 160 and 164) protecting health information (“HIPAA”) may not apply to the recipient of the information and, therefore, may not prohibit the recipient from re-disclosing it.

3.      I understand that I may revoke this authorization at any time except to the extent that Practice has already taken action in reliance on it.

4.      To revoke this authorization, I will provide Julie Abrams, OTR, LLC and/or Amanda Betzen,, OTR, LLC a written revocation, which shall be effective when it has been received..

5. This authorization will automatically terminate one (1) year from the date of signature.

6.      I understand that I may refuse to sign this authorization.

7.      I understand that Julie Abrams, OTR, LLC and Amanda Betzen,OTR, LLC may not condition treatment of me on my willingness to sign this authorization. I acknowledge that I am not seeking either: (1) health care services from Julie Abrams, OTR, LLC and Amanda Betzen, OTR, LLC solely for the purpose of creating protected health information for disclosure to a third party, or (2) research-related treatment.
Child's Name

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Parent's Name

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