Release of Records

Authorization for Estrella Pediatrics to Release Protected Health Information
Patient Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Only the following information will be disclosed by this authorization (records to be included)*

All Medical RecordsImmunization Records OnlyPhysical formExcuse NoteOther, Please Specify
If applicable, I also give permission for the following to be disclosed:

acquired immunodeficiency syndrome (AIDS) or infection with human immunodeficiency virus (HIV)behavioral health services/psychiatric caretreatment for alcohol and/or drug abuse
Name of person/place receiving information:*
For example, parent, another doctor, school etc.
Release information via the following method:*

MailFaxEmailIn personOther
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Fax Number
Please enter a valid phone number.
Email
example@example.com
Reason for Records Release:*

Change of InsuranceRelocation/DistanceTransitioning to Adult PracticeDissatisfaction due to:Other
Reason for dissatisfaction to the practice
Reason for dissatisfaction to the practice;
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the Practice. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. If I fail to specify an expiration date, event or condition, this authorization will expire in One Year from date signed.

I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. The Practice, its employees, officers, and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.
Patient or Personal Representative's Name:*

First NameLast Name
Signature*

Digital submission acts as authorization. Clear
Phone Number (in case we need to reach you)*
Please enter a valid phone number.
Relationship to Patient*
Date*

MonthDayYear
Date
Form revised 06/01/2021
Should be Empty:

Authorization for Estrella Pediatrics to Release Protected Health Information