Medical Records

Authorization for Use and Disclosure of Protected Health Information:

Information Disclosed From

Information Disclosed To:

2 year history will be requested unless specified:

Your Rights with Respect to this Authorization

Drug and/or Alcohol , and/or Psychiatric, and/or HIV/AIDS Records Release:
I understand that the requested information may contain reference to or results of HIV/AIDS (Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome) testing and/or treatment, drug and/or alcohol abuse, psychiatric care, sexually transmitted disease, Hepatitis B or C testing, and/or other sensitive information. I authorize the release of such confidential information to the indicated party, unless prohibited in my instructions above.
Time Limit & Right to Revoke Authorization
Except to the extent that action has already been taken in reliance on this authorization, at any time I can revoke this authorization by submitting a notice in writing to the facility Privacy Officer at Pediatric Assoc. Prof., LLC, 947 S.5th St., Montrose, CO 81401. Unless revoked, this authorization will expire one year from date of signature.
I understand the information disclosed by this authorization may be subject to re-disclosure by the recipient and no longer be protected by the Health Insurance Portability and Accountability Act of 199 6. The facility, its employees, officers and physicians are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein.
Signature of Patient or Personal Representative Who May Request Disclosure
I understand that I do not have to sign this authorization, and my treatment or payment for services will not be denied if I do not sign this form unless specified above under Purpose of Request. I can view or receive a copy of the protected health information to be used or disclosed. I authorize Pediatric Assoc., Prof.,LLC. to use and disclose the protected health information as specified above.
**Copies of Records may be obtained with reasonable notice and payment of copying costs. FEES MAY APPLY. Please allow 7-10 business days to process your request. **

(If legal guardian, provide a copy of the court order establishing person’s authority)

Internal Use Only
Front Desk :

Medical Records: