Authorization to Release Patient Health Information

Authorization to Release Patient Health Information
Patient's Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
Information to be Released FROM:

Provider or facility currently in possession of your records
GROW Pediatrics and Adolescent MedicineOutside Provider/Facility (enter info below)
Outside Provider/Facility (if applicable):
Address:
Phone:
Format: (000) 000-0000.
Fax:
Information To Be Released TO:

Provider/facility or person who should receive your records
GROW PediatricsOutside Provider/Facility or Individual (enter info below)
Outside Provider/Facility or Individual
Address:
Phone:
Format: (000) 000-0000.
Fax:
Purpose Of Release
LegalPersonal UseContinuing CareTransfer to Another ProviderSchoolOther:
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 any time by written notification to GROW PEDIATRICS AND ADOLESCENT MEDICINE, PLLC. 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.
Sensitive records pertaining to the diagnosis and treatment of specifically protected or privileged categories require patient authorization. Please INITIAL which records you authorize us to release:
Drug/Alcohol abuseSexually transmitted diseasesMental HealthHIV/AIDS testingOther:
SIGNATURE OF PATIENT/PARENT/LEGAL REPRESENTATIVE
Signature of Patient/Parent/Legal Representative*
Date*

MonthDayYear
Date
Printed Name of Parent/Legal Representative*
Relationship to Patient*
A minor patient's signature is required to release the following information related to: 1) Reproductive care, such as birth control, pregnancy-related services, and sexually transmitted diseases, including HIV/AIDS (age 14 and older); 2) Substance abuse and mental health treatment (age 13 and older).
Signature of Minor Patient
Date

MonthDayYear
Date
A complete records request takes our office up to 10-14 business days to process. As a courtesy, GROW Pediatrics fulfills one complete records request per patient at no charge, with a $25 fee for any additional requests for records to be provided directly to an individual.
Should be Empty:

Authorization to Release Patient Health Information

Information to be Released FROM:

Information To Be Released TO:

Purpose Of Release

Authorization for General Release of Information

SIGNATURE OF PATIENT/PARENT/LEGAL REPRESENTATIVE