Authorization for Release of Protected Health Information (Outgoing)

This authorization expires 1 year from the date of signing. This request may be revoked by the patient at any time by communicating in writing that intent to the provider.  Requests will be processed within 5 business days.

All form fields are required to be completed.

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

I hereby authorize and consent to disclosing health records as stated below. I am aware that the records disclosed might contain records whose confidentiality is protected by either the Federal Drug & Alcohol Confidentiality Law (42 C.F.R. Part 2) or the State Mental Health Records Law (I.C. 16-39-2). I understand the records released may include alcohol and/or substance abuse, mental health, and communicable disease documentation (including HIV results) unless I specifically prohibit releasing this information.

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 is no longer protected by 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.

1. Patient Information

Patient 1

Patient's Name: 

Patient's Date of Birth:

Patient 2

Patient's Name: 

Patient's Date of Birth:

Patient 3

Patient's Name: 

Patient's Date of Birth:

Patient's address

Patient's city

Patient's state

Patient's zip code

Patient's phone number

2. I Authorize Northpoint Pediatrics to release records to:

Name of Doctor/Person/Organization to whom the disclosure is to be made:

Please choose one:

Fax # for records to be sent to: 

Email to parent's email address:
(Please provide a home email address - not a work email address)

3. The purpose or reason for this disclosure is:

Leaving practice due to:

**If you are moving out of the area, what is the moving date:

**If moving, please list the new address and phone #:

Not leaving the practice - Need records for:

Release of health form to a third party - fee associated is for completion of the form.

4. We are happy to release the following records free of charge, please check which you would like:

 Immunizations
 Growth Curve
 Last well child exam

I understand that there is NO fee for copying the first 10 pages, postage fee only if mailed. $.25 per page (pgs copied after first 10 pgs) plus postage.

Other records:

Signature (Parent/Legal Guardian / 18yr & over Patients)

IF THE PATIENT IS 18 YEARS OR OLDER, THE PATIENT IS HIS/HER OWN LEGAL GUARDIAN AND MUST SIGN THIS FORM TO RELEASE MEDICAL RECORDS INFORMATION.

Requests will be processed within 5 business days.

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

Name:

Date signed: