Authorization for Use or Disclosure of Protected Health Information Logo
  • Peds- Authorization for Use or Disclosure of Protected Health Information

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  • I hereby authorize the use or disclosure of the Protected Health Information described below to be provided to or obtained by the
    following:

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  • Medical information between

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  • I understand:

  • - I release the entities listed above, their agents and employees from any liability in connection with the use or disclosure of the protected health
    information. The entity authorized to disclose the information will not be compensated by the recipient for such disclosure. Normal applicable fees, such
    as copy fees, may apply.

    - Information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer protected by federal law.
    However, the recipient may be prohibited from disclosing substance abuse information under the Federal Substance Abuse Confidentiality Requirements.

    - Unless the purpose of this authorization is to determine payment of a claim for benefits, the requesting entity will not condition the provision of
    treatment, payment, enrollment in a health plan, or eligibility for benefits on obtaining this authorization.

    I understand that the information authorized for use or disclosure may include information which may indicate the presence of a communicable or
    non-communicable disease and may include, but is not limited to, diseases such as hepatitis, syphilis, gonorrhea, and human immunodeficiency viruses
    also known as Acquired immune Deficiency Syndrome (AIDS). I further understand that my medical information may indicate that I have or have been
    treated for psychological or psychiatric conditions or substance abuse.

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  • Description of Representatives Authority to Act for the Patient

  • Notice of Rights: Information in your medical records that you have or may have a communicable or venereal disease is made confidential by law and
    cannot be disclosed without your permission except in limited circumstances including disclosure to persons who have had risk exposures, disclosure
    pursuant to an order of the court or the Department of Health, disclosure among healthcare providers or for statistical or epidemiological purposes.
    When such information is disclosed, it can not contain information from which you could be identified unless disclosure of that identifying information
    is authorized by you, by an order of the court of the Department of Health or by the law.

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