By signing this release, I authorize the above named office/medical provider to release protected health information (PHI) as outlined above to A to Z Peditrics LLC (fax 618-344-9246 or mailed to 1230 Tanglewood Parkway, Caseyville, IL 62232 attn: medical records).
When my child's information is used or disclosed pursuant to this authorization, it may be subject to re-disclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that A to Z Pediatrics LLC has acted in reliance upon this authorization (information released prior to revocation). My written revocation may be submitted to: Privacy Officer, A to Z Pediatrics LLC, 1230 Tanglewood Parkway, Caseyville, IL 62232.
I understand that any fees assessed for copying records of the PHI are my responsibility. Fees are determined by Illinois Public Act 92-228. Future further releases of the information requested at this time will be subject to additional fees. The recipient of this PHI will also require the consent of patient, parent or legal guardian for further release. I understand that I/my child will not be denied treatment if I do not sign this authorization for requested use and disclosure of PHI.