Authorization for the Use or Disclosure of Health
Information
Patient Name: _______________________________ Date of Birth: ____________________
I request release of my child’s health information:
From: Office Name:
_________________________________________________
Doctor’s
Name: ________________________________________________
Address:
_____________________________________________________
_____________________________________________________
Phone:
______________________________________________________
Fax:
________________________________________________________
To: Desert Ridge Children’s Center
Phone: 480-585-5200
Fax: 480-585-5233
The health information
to be used/disclosed includes: (check all that apply)
□ All health information including but not limited to AIDS/HIV
and other communicable disease information, behavioral health care/psychiatric
care, alcohol and or drug abuse treatment, if any, unless specifically
accepted: ____________________________________________________________
□ Health
information relating to the following condition: ______________________________
□ Immunization
record
This authorization
ends: (check only one)
□ on this date ______________________________
□ 6
months from the date of authorization (this is default if no box is checked)
I hereby request and consent that my medical records and
non written records be sent to my referring physicians, those physicians or
ancillary facilities that I am referred to by Desert Ridge Children’s Center
and to my insurance company or its agents that may be authorizing
treatment. I further understand that I
do not have to sign this authorization in order to get health care benefits. I understand that I may revoke this
authorization in writing at any time except to the extent that Desert Ridge
Children’s Center has acted in reliance upon this authorization. Once this office discloses health
information, the person or organization that receives it may re-disclose it
(dependent on their policy) and Desert Ridge Children’s Center does not take
responsibility for the protection of this information.
Signature of
parent/legal guardian: _________________________________ Date: ____________
Relationship to
Patient: _____________________________________________________________