healthy kids care

Above listed patient authorizes HEALTHY KIDS CARE to make record disclosure:

Healthy Kids Care – Administrative Services Policy

We Kindly Ask For Your Understanding And Cooperation Regarding Our Policy For Completing Medical Forms And Administrative Paperwork.

______ In Accordance With Nevada Law, The Medical Practice May Charge A Reasonable Fee For The Copying And Preparation Of Medical Records. Fees May Include Charges For Copying, Printing, Supplies, And Administrative Labor Associated With Fulfilling The Request. Any Applicable Fees Must Be Paid Prior To The Release Of Records Unless Otherwise Required By Law. Patients May Request An Estimate Of Applicable Fees Before Records Are Prepared.

______ I Authorize The Practice To Use And Disclose The Protected Health Information Described In This Authorization To The Individual Listed Above. This Authorization Is Made In Accordance With The Health Insurance Portability And Accountability Act (HIPAA). Information Disclosed Under This Authorization May Be Subject To Redisclosure By The Recipient And May No Longer Be Protected By Federal Privacy Regulations. Unless Otherwise Specified, this Authorization Will Expire One (1) Year From The Date Of Signature.

For The Protection Of Patient Privacy, Valid Government‐Issued Photo Identification Is Required When Medical Records Are Picked Up In Person.

Please Allow Up To 15 Business Days For Completion Of Any Formal Paperwork Or Documentation Request. Expedited Requests May Not Always Be Available.