VOICE MAIL AUTHORIZATION FOR THE RELEASE OF HEALTHCARE INFORMATION*

AUTHORIZATION FOR THE RELEASE OF HEALTHCARE INFORMATION*

Pediatric Development Center of Atlanta, LLC

3200 Highlands Pkwy SE Ste 150

Smyrna, GA 30082

770-433-2300

Your Name*

First NameLast Name

Your Child's Legal Name*

First NameLast Name

Child's Date of Birth*

Relationship to Child*

On behalf of my child (Legal Name listed above), I authorize Pediatric Development Center of Atlanta, LLC, to disclose healthcare information relating to Therapy Services and Appointment Scheduling by Voice Mail at the phone number(s) listed below.

Please type the individual names or entities and their contact telephone numbers on separate lines*

The purpose is to communicate necessary information, and appointment scheduling information including but not limited to, appointment reminders, appointment cancelations and modifications.

This Authorization may or may not, (please select below), be used for the release of additional information to the same person, or entities for the same or related purposes*

This Authorization will remain in effect until*

Date

You, the parent, may refuse authorization to disclose all or some healthcare information but that refusal may result in improper diagnosis or treatment, denial of coverage or a claim for health benefits or other insurance or other adverse consequences.

You, the parent, may revoke this authorization at any time by executing a written revocation, subject to the right of any person who acted in reliance on the authorization prior to receiving notice of revocation. If you do revoke this authorization, that action could result in the denial of health benefits or other insurance coverage or benefits.

You, the parent, must deliver the revocation of your authorization to us by hand, certified mail or by express delivery service.

You are entitled to a copy of this authorization.

Signature of Parent*

Clear

Date*

Date

*This form is required by 45 C.F.R. § 164.508(c) and O.C.G.A. § 31-33-2.