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