CELEBRATION PEDIATRICS ASSOCIATES, P.A. AUTHORIZATION TO RELEASE OR USE INFORMATION FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS
I (GUARDIAN LISTED ABOVE), hereby authorize the release or use of my dependents individually identifiable health information (PHI "Protected Health Information") and medical record information by Celebration Pediatrics Associates, PA, in order to carry out treatment, payment, or health care operations on behalf (THE PATIENT LISTED ABOVE) Associates, PA Notice of Privacy Practices for a more complete description of the potential release and use of such information. You have the right to review such Notice prior to signing this consent from.
We reserve the right to change the terms of the Notice to Privacy Practices at any time. If we do make changes to the terms, you may obtain a copy of the revised notice.
You retain the right to request that we further restrict how your dependent's PHI is released or used to carry out treatment, payment, or health care operation. Our practice is not required to agree to such requested restriction: however, if we do agree to your requested restriction(s), such restrictions are then binding on the practice.
I acknowledge and agree that the practice may disclose my dependent's PHI and medical record information, confirm or change appointment times and speak to the office on my dependent's behalf with the following individuals who are family members, legal representatives, guardians, healthcare surgeons, or have power of attorney: