I give permission to Essex Pediatrics to speak with my parents/guardians and discuss general information from my medical record for the purpose of continuation of treatment.

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

The following medical records have special protections. I give my specific permission to discuss the records that are selected and initialed below.

I understand that:

• The recipient authorized to receive my information may not be required to protect my information and may share my records without my permission.
• Signing this form is voluntary. I do not need to sign this form to receive health care services at Essex Pediatrics.
• I may cancel this authorization at any time by providing written notice to Privacy Officers, Sue Rogers-Low or Jill Kenneson at 89 Main St, Essex Junction, Vermont, 05452. My revocation will not apply to the information that has already been released in response to this authorization.
• I may inspect or copy any information to be used or disclosed under this authorization.
• Unless otherwise cancelled in writing, this authorization will automatically expire one year from the date I sign below.