Transfer Records to Bi-County Pediatrics
 
 

BI-COUNTY PEDIATRICS, P.C.

6128-D Prestley Mill Rd.

Douglasville, GA 30134

(770) 949-3888   Fax (770) 949-3504

 

AUTHORIZATION TO RELEASE HEALTH INFORMATION

 

 

Patient Name: ________________________________________________  DOB: ___________________

 

 

1.  The type and amount of information to be used or disclosed is as follows:

 

            ?  Complete record, excluding HIV (AIDS), mental health, and substance abuse information, if any.

            ?  History & Physical                             ?  Consultations                        ?  Laboratory

            ?  Progress Notes                                 ?  Immunization Records           ?  Radiology Reports

            ?  Other: _____________________________________________

 

            ?  HIV/AIDS ___________     ?  Mental Health ____________           ?  Substance Abuse __________

                                  Pt’s Initials                                     Pt’s Initials                                         Pt’s Initials

                                                                                          

 

 

2.  I hereby authorize ___________________________________________________________

 

                                    Phone #__________________________ to release the above medical information to

 

                                                                           Bi-County Pediatrics

                                                                           6128-D Prestley Mill Rd.

                                                                           Douglasville, Ga 30134

                                                                           Phone (770) 949-3888,   fax (770) 949-3504.

 

I understand that this will include HIV (AIDS), mental health, and/or substance abuse test results, only if so designated.  I further agree to release the above named facility, its affiliates, employees, and physicians from all legal responsibility and liability that may arise from the disclosure and/or unauthorized redisclosure of such information.  I understand that I have a right to revoke this authorization at any time.  I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the health information department.  I understand that the revocation will not apply to the information that has already been released in response to this authorization.  Unless otherwise revoked, this authorization will expire on the following date: _____________________________.  If I fail to specify an expiration date, this authorization will expire in one (1) year from the signature date below.

I understand that authorizing the disclosure of this health information is voluntary.  I understand that the medical provider may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.

If I have questions about disclosure of my health information, I can contact the Health Information Manager or the Office Manager.

 

Signature of Parent/Legal Guardian _________________________________________ Date ____________

 

Relationship ________________________________________________

 

Signature of Witness _____________________________________________________ Date _____________