Form Hipaa - Authorization For Release Of Information June 2012
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1PLEASE RETURN THIS FORM
Phillip Harmon, M.D.
Rebecca Webster, M.D.
TO ONE OF THE FOLLOWING LOCATIONS:
Mark Lytle, M.D.
Katherine Rochelle, M.D.
Diane Dietlein-Cox, M.D.
Angela Redmond, M.D.
Pediatrics East - Deerfoot
Pediatrics East - Trussville
Peily Soong, M.D.
Gigi Youngblood, M.D.
6729 Deerfoot Parkway
520 Simmons Dr
Michael Miller, M.D.
Diane Kutny, M.D.
Pinson, AL 35126
Trussville, Al 35173
PHONE: (205) 681-5377
PHONE: (205) 661-4680
FAX: (205) 212-7102
FAX: (205) 212-7102
.
.
Children’s of Alabama - Authorization for Release of Information
Patient Name (First, MI, Last):____________________________________________________________
Address/City/State/Zip: __________________________________________________________________
Phone Number: (____) _______________________________Date of Birth: ________________________
This Authorization applies to the following Information:
All Information
. I understand that the information may contain psychiatric/psychological, alcohol/drug abuse,
and/or AIDS/HIV information and I expressly consent to the release of the information.
Only
the following records or types of Information:___________________________________________________
Treatment Dates: from (month/day/year) _____/_______/______ to (month/day/year) _____/_____/_____
I consent for my child’s medical records to go:
I consent for my child’s medical records to go:
To:
From:
Practice Name:
Practice Name:
OR
Address:
Address:
City/State/Zip :
City/State/Zip :
Phone:
Phone:
From:
To:
Origin Name: ______________________________
Origin Name: ____________________________
Address: _________________________________
Address:________________________________
City/State/Zip: _____________________________
City/State/Zip: ___________________________
Phone: ___________________________________
Phone: ________________________________
Purpose of the release:
Continuity of Treatment
Other (Please specify________________________)
I understand the Information released will be limited to information necessary to fulfill the need or purpose
for the disclosure. If I have authorized the disclosure of Information to a recipient who is not subject to the Health
Insurance Portability and Accountability Act of 1996 ("HIPAA"), then the recipient may re-disclose it and it may no longer
be protected under HIPAA, a federal privacy law. This Authorization is valid for ninety (90) days from the date of
signature, unless otherwise noted. This Authorization only applies to treatment occurring before the date of signature. I
may decline to sign this Authorization. I understand I may revoke this authorization in writing at any time by completing a
form available from Pediatrics East. If I revoke this authorization, the revocation will not apply to information that has
already been released in response to this authorization. I understand the patient's health care and the payment for the
patient's health care will not be affected if I do not sign this form. I understand I may see and copy the Information
described on this form if I ask for it, and I may receive a copy of this form after I sign it. Before requesting medical record
copies, please ask about the copy fee by law that may apply. I represent that I have the authority to and voluntarily grant
permission for the Information to be released as described above.
_____________________________________
__________________________________________
Patient/Parent/Legal Guardian Printed Name
Patient/Parent/Legal Guardian Signature
Date
________________________________________
__________________________________________
Patient Signature if Adult (ie.19 or older)
Date
Witness Signature
Date
HIPAA Authorization specific request 6-26-12
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