Request for Release of Medical Information
I Authorize Northpointe Pediatrics to release medical records to
Address
City
State
Zip
Phone
Fax
...to release certain protected health information (PHI) about my child/ren listed below including any which may relate to:
The information to be disclosed from medical record
Specific dates of service
(list specific dates or event)
Entire medical/vaccine record
Last checkup/vaccine record
Other (please state reason)
Purpose of this request
This information is being released for the specific purpose stated above. I further understand that records from other healthcare providers will not be released with this request, nor will this information or record be made available to any other person or agency unless another authorization is obtained. This consent can be revoked in writing, except in those circumstanced in which the information had already been released. I understand signing this form is voluntary and I do not need to sign this form to assure treatment. When this information is used or disclosed as requested by this authorization, it may be subject to disclosure by the recipient and may no longer be protected by federal HIPAA Privacy Rule. This authorization will expire 3 months from date of my signature or upon completion of forwarding records to named party.
Child/ren
Name
Date of Birth
Name
Date of Birth
Name
Date of Birth
Signature of Parent or Legal Guardian
– Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
Patient/Parent/Guardian Name
Date