Authorization to Share Medical Information with Another Party

Authorization to Share Medical Information with Another Party

Essex Pediatrics • 89 Main Street, Essex Junction, VT 05452 • (802) 879-6556
Patient Name*
Patient Date of Birth*

MonthDayYear
Date
I give Essex Pediatrics permission to share with another party general information from the patient’s medical record for the purpose of continuation of care.

This permission includes office notes, medication lists, laboratory/radiology reports, problem lists, immunizations, specialty notes, hospital admissions and emergency room reports.

The following medical records have special protections. I give specific permission to share the records that are selected below.
I give permission to share mental health records.*

YesNo
I give permission to share HIV/AIDS and sexually transmitted infection records.*

YesNo
I give permission to share alcohol/drug treatment records.*

YesNo
I give permission to share sexual abuse/assault and domestic violence records.*

YesNo
Patient/Parent/Guardian 1
Name*
Primary Phone*
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.
Patient/Parent/Guardian 2
Name*
Primary Phone
Please enter a valid phone number.
Medical Information To Be Sent To:
Recipient Name*
Phone Number*
Please enter a valid phone number.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorization
I understand that:
- I may cancel this authorization at any time by providing written notice to Privacy Officers, Sue Rogers-Low or Jill Kenneson at 89 Main Street, Essex Junction, VT, 05452.
- My revocation will not apply to the information that has already been released in response to this authorization.
- Unless cancelled in writing, this authorization will automatically expire one year from the date I sign below.
Patient/Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Authorization to Share Medical Information with Another Party

Patient/Parent/Guardian 1

Patient/Parent/Guardian 2

Medical Information To Be Sent To:

Authorization