Authorization for Release of Protected Health Information (Incoming)

This request is good for 60 days from the date signed pursuant to I.C. 16-39-1-1 unless indicated otherwise. This request may be revoked by the patient at any time by communicating that intent in writing to the provider.


All fields are required

By filling out this form, you are agreeing to the following:

  • I understand that the information used or disclosed may be subject to redisclosure by the person(s) or class of person(s) receiving it and no longer protected by the federal privacy regulations.
  • I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment.
  • I hereby authorize and consent to disclosure of health records as stated below. I am aware that the records disclosed might be records whose confidentiality is protected by either Federal Regulations (42 C.R.F., Part 2) or State Regulations (I.C. 16-39-16). The records may include alcohol and/or substance abuse and mental health documentation as well as HIV results.

Please note: There may be a charge assessed by your previous physician’s office for copying the medical record. Please contact them for more information.

Patient Information

Name of doctor at Northpoint Pediatrics​

Patient's name

Date of Birth

Patient's address

Patient's city

Patient's state

Patient's zip code

Patient's phone number

I Authorize Northpoint Pediatrics to receive information from:

Name of Practice or Organization releasing information to Northpoint Pediatrics

Practice or Organization’s​ phone number

Information to be disclosed:
 

 

If you choose other, you must indicate what information to share:

Date range

Practice or Organization’s address

Practice or Organization’s city

Practice or Organization’s state

Practice or Organization’s zip code

How should records be sent to Northpoint Pediatrics?
 
 
 

Name of person filling out the form

Sign your name:

Please use your mouse, stylus, or finger to sign your name in this box.

Date signed