Authorization for Release Form

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

I hereby authorize you to furnish certain protected health information (PHI) about my children to:

Physician:

Other Health Care Provider:

Insurance Company:

Legal:

Hospital:

Camp/School:

This authorization will expire on the termination of my child(ren)'s care at Healthy Kids Pediatrics.

The information will be used or disclosed at my request as the patient's parent.

The practice will not receive remuneration from a third party, excluding legal counsel, in exchange for using or disclosing my child(ren)'s PHI.

I do not have to sign this authorization in order to receive treatment from Healthy Kids Pediatrics. I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and is no longer subject to the HIPAA privacy rule. I have the right to revoke this authorization, except to the extent that the practice has acted in reliance upon this authorization. My written revocation must be submitted in writing to the Privacy Officer at 675 Franklin Avenue, Nutley, NJ 07110

Signed by:

Parent or Legal Guardian:

Child(ren)'s Name(s)

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