Authorization to Use or Disclose Protected Healthcare Information

Patient Legal Name*

First NameLast Name

Date of Birth*

Date

Previous name

First NameLast Name

What number can we call you at?*

Area CodePhone Number

Is this a transfer of care?*

YesNo

Richmond Pediatrics may use or disclose the following healthcare information (Check all that apply)*

Release all health care information in medical recordRelease specific medical records

Please specify what medical records to release. Please be as specific as possible.

e.g. health care information relating to specific treatment, conditions or dates.

Where are the records being sent?*

Richmond Pediatrics is receiving records from the organization or entity below.Richmond Pediatrics is sending records to the organization or entity below.Richmond Pediatrics and the organization or entity below are authorized to exchange records and information.

Please specifiy below what organization or enity this authorization is for below.

If this is being requested for personal records, please enter your name and phone number.

Name of Organization or Entity that Richmond Pediatrics is authorized to send or request records from*

Organization or Entity Address*

Street Address

Street Address Line 2

CityState

Zip Code

Organization or Entity Fax Number

Area CodePhone Number

Organization or Entity Phone Number

Area CodePhone Number

This authorization ends*

Expires in one year from the date signed unless specified belowDate belowWhen the following event occurs

Authorization end date*

Date

Authorization ends when this event occurs

1. I understand that I do not have to sign this authorization in order to get health care benefits (treatment, payment, enrollment, or eligibility for benefits). However, I do have to sign an authorization form:

to receive research-related treatment in connection with research studies or
to receive health care when the purpose is to create health care information for a third party.

2. I may revoke this authorization in writing at any time. If I do, it will not affect any action taken by Richmond Pediatrics in reliance on this authorization before it receives my written revocation. I may not able to revoke this authorization if its purpose was to obtain insurance. Two ways to revoke this authorization are:

Fill out a revocation form - a form is available from Richmond Pediatrics or
Write a letter to Richmond Pediatrics

3. Protection after Disclosure. I understand that once my health care information is disclosed, the person or organization that receives it may re-disclose it and that privacy laws may no longer protect it.

Patient or Legally Authorized Signature

Clear

Printed Name (If Signed on Behalf of the patient)*

First NameLast Name

Relationship to Patient*

Date*

Date

Minors - A minor patient's signature is required in order to disclose information related to

Reproductive Care
Sexually transmitted diseases (if age 14 and older)
HIV/AIDS (if age 14 and older)
Drug and/or alcohol abuse (if age 13 and older)
Mental Health or illness (if age 13 and older)

Use and Disclosures Requiring Specific Authorization

You may use or disclose healthcare information regarding testing, diagnosis, and treatment for:

(Check all that apply - if nothing is checked, this information will NOT be released )

By signing, I am attesting that I am the patient listed above and authorize the release of my medical records the individual or organization indicated.

Minor Patient's Signature

Clear

Date

Teen Phone Number

Area CodePhone Number

Authorization to Use or Disclose Protected Healthcare Information

1. Authorization

II. My Rights

IV: To be Completed by Patient -- Ages 13-17 years