AUTHORIZATION TO RELEASE / OBTAIN / DISCUSS PROTECTED HEALTH INFORMATION

 

AUTHORIZATION

I understand that all medical information is confidential and that patient records are the property of Beach Baby Pediatric Therapy, LLC.

I authorize Beach Baby Pediatric Therapy, LLC to release, obtain, and verbally discuss protected health information with the individuals and/or entities listed above for the purposes indicated. This includes written records, electronic communication, and verbal communication (in person, phone, or virtual) regarding the patient’s evaluation, treatment, progress, scheduling, billing, and coordination of care.

LEGAL REQUESTS / SUBPOENAS

I understand that Beach Baby Pediatric Therapy, LLC may be required to disclose patient information in response to a valid subpoena, court order, or other legal process, as permitted or required by law.

I understand that, when applicable, reasonable efforts may be made to notify the parent/legal guardian prior to disclosure, unless prohibited by law or court order. I acknowledge that authorization from me may not be required for such disclosures under applicable laws.

LIABILITY AND REDISCLOSURE

I will not hold Beach Baby Pediatric Therapy, LLC, including but not limited to any of its personnel, owners, employees, contractors, officers, members, agents, representatives, or directors responsible for any damage, physical or mental, which may be caused by the release or discussion of patient information.

I further understand that the person or organization that receives this information may disclose it to other individuals or organizations without my knowledge or consent and that such information may no longer be protected under applicable privacy laws. Therefore, I hereby release Beach Baby Pediatric Therapy, LLC, including but not limited to any of its personnel, owners, employees, contractors, officers, members, agents, representatives, or directors from liability relating to or arising out of the release or discussion of information contained in the patient’s records.

INSURANCE DISCLOSURE

I understand that if this authorization is used for disclosure to an insurance company, the insurance company may have the legal right to use the information to determine eligibility, benefits, or to contest coverage.

EXPIRATION AND REVOCATION

This authorization will remain in effect from the date of signature until revoked in writing or upon discharge from services.

I understand that I have the right to revoke this authorization at any time by providing written notice to Beach Baby Pediatric Therapy, LLC. I understand that revocation will not apply to information that has already been released or actions taken in reliance on this authorization.

SIGNATURE

I have read, understand, and agree to all of the above information and hereby authorize Beach Baby Pediatric Therapy, LLC to release, obtain, and discuss information as it concerns the patient listed above.