HIPAA AGREEMENT
This form is SECURE and HIPAA compliant
Patient Name
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First Name
Last Name
Date of Birth of patient
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Month
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Day
Year
Date
Name of additional child to be added to this HIPAA agreement
First Name
Last Name
Date of Birth of additional child to be added to this HIPAA agreement
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Month
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Day
Year
Date
Name of additional child to be added to this HIPAA agreement
First Name
Last Name
Date of Birth of additional child to be added to this HIPAA agreement
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Month
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Day
Year
Date
Name of additional child to be added to this HIPAA agreement
First Name
Last Name
Date of Birth of additional child to be added to this HIPAA agreement
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Month
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Day
Year
Date
I give consent to the doctors of Gurnee Pediatrics (formerly Gabriel Pediatrics), to use or disclose all information contained in my child's/children's medical record for the purpose of carrying out treatment, payment and/or continuity of my child/children's care. I give consent to the doctors and office staff to leave messages containing personal health information as I have designated on my registration form.
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Please upload a picture of your Driver's License to verify your identity
*
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Name of Parent/Legal Guardian
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First Name
Last Name
I authorize the following person to access and/or obtain a copy my child/children's private medical record or personal health information:
First Name
Last Name
Authorized person’s DOB
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Month
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Day
Year
Date
Relationship to patient
I authorize the following person to access and/or obtain a copy my child/children's private medical record or personal health information:
First Name
Last Name
Authorized person’s DOB
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Month
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Day
Year
Date
Relationship to patient
I understand that I may revoke this consent anytime by giving a written notice to the office. I acknowledge that I can obtain a copy of the Physician Notice of Privacy Practices upon my request. (The PNPP is posted in the office receptionist area and available on our website) By signing, I acknowledge that I have read, understood and agree with the above HIPAA Agreement
*
Please upload a picture of your Driver's License to verify your identity
*
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Choose a file
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Name of Parent/Legal Guardian
*
First Name
Last Name
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