Pediatric Consultants of Ashland and Mansfield

Pediatric Consultants of Ashland and Mansfield

HIPAA/Treatment of Minors Consent

1HIPAA Authorization > 2Treatment of Minors Consent
HIPAA Authorization
Patient Name Patient Name First Last
Date of Birth Date of Birth / MM / DD YYYY
School/Preschool/Daycare
Appointment Information Medical Information prescriptions, treatment, labs, etc.
Voice Mail
Appointment Information Medical Information prescriptions, treatment, labs, etc.
Other (list people/places below)
Appointment Information Medical Information prescriptions, treatment, labs, etc.
If checked other above, list people and/or places:
I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the practice's Privacy Officer at 1522 Claremont Ave., Ashland, Ohio 44805. I understand that a revocation is not effecive to the extent that my physician has relied on the use of disclosure of PHI or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. This authorization expires three years from signed date.
I have read and understand the information above regarding HIPAA

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