FORM: AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION
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FILL OUT THIS FORM IF YOU WANT US TO GET OLD MEDICAL RECORDS FROM PREVIOUS DOCTORS.
Dear Parents/ Guardians:
This authorization may be used to permit a covered entity (as such term is defined by HIPAA and Florida Law) to use and/or disclose an individual’s protected health information. Individuals completing this form should read the form in its entirety and understand this form before signing and complete all the sections that apply to their decisions relating to the use or disclosure of their protected health information. Every person has a right to privacy of their medical records. You can choose to disclose certain health related information with individuals of your choice.
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Patient for whom authorization is made:
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PLEASE SEND RECORDS TO:
GOLD STAR PEDIATRICS
3149 BOBCAT VILLAGE CENTER ROAD.,
NORTH PORT, FL 34288
Information to be disclosed: Please check/WRITE IN the appropriate field
Please indicate by Initialing in each box.
The individual signing this form agrees and acknowledges as follows:
(1) Voluntary Authorization: This authorization is voluntary. Treatment, payment, enrollment or eligibility for benefits (as applicable) will not be conditioned upon my signing of this authorization form. I have read this whole form, I understand this form completely, I was given the opportunity to ask questions regarding this form and its authority, and I consent to this form voluntarily.
(2) Authority: The individual signing this form hereby acknowledge that they are a legal parent, guardian, or representative of the individual for whom this form is signed and whose information will be disclosed.
(3) Effective Time Period: This authorization shall be in effect for one year from the date signed or the following specified date: Month: ________ Day: ________ Year: _________.
(4) Right to Revoke: The individual signing this form hereby acknowledge that they understand that they have the right to revoke this authorization at any time by writing to the health care provider or health care entity listed above. The individual signing this form hereby acknowledge that they understand that they may revoke this authorization except to the extent that action has already been taken based on this authorization.
(5) Special Information: This authorization may include disclosure of information relating to DRUG, ALCOHOL and SUBSTANCE ABUSE, MENTAL HEALTH INFORMATION, except psychotherapy notes, CONFIDENTIAL HIV/AIDS-RELATED INFORMATION, and GENETIC INFORMATION only if the person filling out this form places their initials on the appropriate lines above. In the event the health information described above includes any of these types of information, and I initial the corresponding lines in the box above, I specifically authorize release of such information to the person or entity indicated herein.
(6) Signature Authorization: The person filling out this form has read this form and agree to the uses and disclosure of the information as described. The person filling out this form understands that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission. The person signing this form understands that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state privacy laws.
