Authorization to Release Health Information

Patient Information
Name of Patient*
Birth Date*

MonthDayYear
Date
Primary Telephone*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Authorizes

This is your current provider who will be releasing your information
Are you transferring from Sturdy Pediatrics as a patient of Dr. Hansen or any other provider?

YesNo, I am coming from another office
Name of Current Healthcare Provider*
Street Address
City*
State*
Zip Code
Telephone
Fax
Name of Current Healthcare Provider*
PLEASE INCLUDE THE OFFICE NAME, ADDRESS, TELEPHONE AND FAX SO THAT WE CAN CONTACT THEM ON YOUR BEHALF TO REQUEST YOUR MEDICAL RECORDS.
Street Address
City*
State*
Zip Code
Telephone
Fax
Release Health Information to Peak Pediatric Care
Name of New Healthcare Provider*
PLEASE LEAVE PEAK PEDIATRIC CARE NAME AND ADDRESS - DO NOT CHANGE TO YOUR PERSONAL DETAILS
Street Address
City*
State*
Zip Code
Telephone*
Fax*
Purpose of Disclosure

Check applicable categories
Reason for authorizing release of your health information*

Transferring to PeakTransferring from PeakFurther MedicalLegal ActionSchoolPersonal UseOther
Information to Release
Please select which information you need released*

Entire Medical Record (except confidential information defined by Massachusetts law)Medical Record for a specific period of time. Please list time period below.Only information from a certain illness or injury. Please describe below.
Please release my medical records fromblanks* to blank*
Sensitive Information
By putting my initials by each item below I give permission for Peak Pediatric Care to receive/share this type of information. I understand that if I do not initial the box, Peak Pediatric Care will not receive/share this information about me/the patient's health to the person or organization listed above.
Information about Mental Health Communications

Clear
Information about HIV/AIDS Testing or Treatment

Clear
Information about Venereal Disease (STD)

Clear
Information about Substance (i.e. alcohol or drug) Abuse

Clear
Information about Sexual Assault

Clear
Information about Genetic Testing

Clear
YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION:
I know I can revoke this form at any time. This means I can tell Peak Pediatric Care to stop sharing my/the patient's information. I know I cannot withdraw information that Peak Pediatric Care had shared before I told Peak Pediatric Care to stop. Peak Pediatric Care may already have shared it. If I no longer want my/the patient's medical record shared I will send a written letter to Peak Pediatric Care telling them

I know I do not have to give permission to share these records. Peak Pediatric Care will not base my/the patient's treatment on whether or not I sign this form.

This approval will end in 12 months or sooner if I send a written letter to Peak Pediatric Care telling them

By signing below I agree that I understand the above and voluntarily allow my/the patient's medical record
Patient's Name*
Parent/Legal Guardian's Name (if applicable)
Relationship to Patient
Signature of Parent / Legal Guardian / Self (if 13+)*

Clear
Date*

MonthDayYear
Date
Patients under the age of 18 may be allowed to provide or decline release without parental consent under Massachusetts law.
Release forms are required for each registered child at Peak. After submitting this form, do you need to complete another medical records release form for another registered child?*

Yes, I have to complete another release form for a child I registered at PeakNo, I do not have any other medical record release forms to complete
Should be Empty:

Patient Information

Authorizes

Release Health Information to Peak Pediatric Care

Purpose of Disclosure

Information to Release

Sensitive Information

YOUR RIGHTS WITH RESPECT TO THIS AUTHORIZATION: