healthy kids care

Above listed patient authorizes the following healthcare facility to make record disclosure:

Ranging date:

Hipaa Authorization Statement

I understand that I may revoke this authorization at any time by submitting a written request to the medical office listed above, except to the extent that action has already been taken in reliance on this authorization.I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. I understand that information disclosed under this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations. This authorization will expire one (1) year from the date of signature unless otherwise specified here:

I understand that this authorization may include disclosure of information relating to mental health treatment, HIV/AIDS testing, genetic testing, or substance use treatment unless otherwise limited in writing.

I certify that I have read and understand this authorization and voluntarily agree to the release of my medical information as described above.