• Authorization to Use or Disclose Protected Healthcare Information

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  • 1. Authorization

  • 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.

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  • II. My Rights

  • 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. 

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

  • 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.

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