Release of Information

Patient Name*

First Last

Date of Birth*

Current Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

1. My Authorization

Pediatrics Northwest may use or disclose the following health care information (check all that apply):*

All health care information in my medical record
Health care information in my medical record relating to a treatment, condition, or date of service
Verbal exchange of information

Please specify the treatment, condition, or date of service.*

Pediatrics Northwest may NOT use or disclose health care information regarding testing, diagnosis, and treatment for (check all that apply):

HIV (AIDS virus)
Sexually transmitted diseases
Psychiatric disorder/mental health
Drug and/or alcohol use

Pediatrics Northwest may disclose this health care information to:

Name (or title)

Organization*

Phone*

Fax

Address*

Street Address Address Line 2 City State ZIP Code

Reason(s) for this authorization (check all that apply):*

At my request
Continuity of care
For marketing purposes for PNW
PNW will be paid for providing this information for marketing purposes
Other

Explain*

PNW Prices and Fees:

Please note, only certain requests will be billed to the requester. There is no fee for transferring records to another medical provider.

$1.24 per page for the first 30 pages.
$0.94 per page thereafter.
$28 clerical fee to everyone *EXCEPT* the Parent/Patient (when requesting records for self)

This authorization ends:*

In 90 days from the date signed
On a specific date
When the following event occurs

(This document does not permit disclosure of health care information created more than 90 days after the date it is signed)

Date*

Specify:*

2. My Rights

I understand I do not have to sign this authorization in order to get health care benefits (treatment, payment or enrollment). However, I do have to sign an authorization form:

To take part in a research study, or
To receive health care when the purpose is to create health care information for a third party

I may revoke this authorization in writing. If I did, it would not affect any actions already taken by PNW based upon this authorization. I may not be able to revoke this authorization if its purpose was to obtain insurance. Two ways to revoke this authorization are:

Fill out a revocation form. A form is available from PNW, OR
Write a letter to PNW.

Once health care information is disclosed, the person or organization that receives it may re-disclose it. Privacy laws may no longer protect it.

Name of Patient (over the age of 18) or Legally Authorized Individual (parent, guardian, etc.) signing:

First Name*

Last Name*

Relationship to Patient*

Date*

IMPORTANT: If the patient is between the ages of 13-17 years old, they will also need to sign. Please sign and submit the form below, then have the minor patient add their signature on the next page.

Authorization for Pediatrics Northwest, P.S. (PNW) to Use or Disclose My Health Care Information

1. My Authorization

PNW Prices and Fees:

2. My Rights

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