On occasion, you may wish to have your Child brought to the Clinic by someone other than a parent. Please list the names of those individuals who have your permission to bring your child in for assessment and/or treatment. A day care worker of grandparent is an example of someone you would allow to bring your child in. If you do not want anyone to be authorized, please write NONE on the name line and sign at the bottom.
The Child listed in this packet may be brought in for assessment and treatment by the following individuals:
By signing below I also acknowledge that I received a copy of the Financial Policy and Summary of Notice of Privacy Practices.
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Medical Record Release
Send Data To
Idaho Falls Pediatrics 3067 Eagle Drive, Ammon, ID 83406 or fax to: (208) 552-7521
Please Release the Following Protected Health Information
The Protected Health Information is being used or disclosed for the following purpose(s): (If the patient is requesting the release, this may state "at patient's request")
Expiration Date of Release
I understand that I have the right to revoke this authorization in writing by sending notification to the address above.
I understand that when I revoke this authorization it is not effective to the extent that the clinic has already relied on the use or disclosure of the Protected Health Information.
I understand that the Protected Health Information released pursuant to this authorization might be re-disclosed by the party who receives that information and may no longer be protected by federal or state law.
The clinic will not base my treatment or payment on whether I provide an authorization for the requested use of disclosure unless the provision of health care is solely for the purpose of creating Protected Health Information for disclosure to a third party.
I understand that I have a right to inspect or copy the Protected Health Information to be used or disclosed.
I understand that I have a right to refuse to sign this authorization.
If you have any questions concerning this form please contact the clinic manager.
Type your name to sign electronically.
In our efforts to improve your overall experience, our practice would appreciate you taking some time to answer a few questions.
This information assists us in a better patient focused approach to your care.
Circle the answer that is most appropriate to your situation.