I hereby attest that I am the patient identified above or the parent or legal guardian of the patient identified above.
I hereby authorize Panhandle Health District to release the immunization records of the patient named above to the aforementioned individual(s) or organzation(s).
Release of this information is voluntary and protected by law. I understand that I do not have to sign this authorization in order to obatain health care benefits (treatment, payment, or enrollment).
I acknowledge that incomplete forms cannot be processed, and telephone requests will not be honored. I understand requests must be made either in writing or electornically using the Authorization for Release of Information.
The facility, its employees, officers, and contracting providers are released from legal responsibility or liability for the release of the above information to the extent indicated and authorized herein. I specifically authorize the disclosure and release of the information to the persons/organization indicated above.
I understand that I may revoke this authorization at any time, except to the extent that action based on this authorization has already been taken. To revoke this authorization, I must submit my written request to the Panhandle Health District.
This authorization will automatically expire one year from the date signed. Authorizations to disclose your information to an employer or financial insititution can only be effective for a maximum of one year from the date signed by you.
Disclosure of this information by any entity subject to HIPAA privacy regulations to a person/entity may be subject to re-disclosure by the recipient without my further authorization.
I understand that I am entitled to receive a copy of this authorization upon my request. A digital signature is considered as valid.
I understand that I may be contacted by Panhandle Health District for additional information if the records of the patient identified above cannot be identified or confirmed based on the information provided.