1684 Foote Avenue Extension 117 Main Street

Jamestown, NY 14701 Randolph, NY 14772

Phone: (716) 661-9730 Fax: (716) 661-9732 Phone: (716) 358-KIDS (5437) Fax: (716) 358-5438

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION OR RECORDS

Patient name: Date of birth:

Address: Phone:

Social Security #:

Information or records to be used/disclosed/released:

r Medical Records from (insert date): ______to (insert date): ______

r Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, and radiology studies

r Alcohol/Drug Treatment

r Mental Health Information

r HIV-Related Information

r Other:

( ) I authorize the release of said information or records TO Southern Tier Pediatrics Practice, P.C. FROM:

Doctor/Facility/Other Party receiving information Phone number

Street address or P.O. Box/City/State/Zip

~AND/OR~

( ) I authorize the release of said information or records FROM Southern Tier Pediatrics Practice, P.C. TO:

Doctor/Facility/Other Party receiving information Phone number

Street address or P.O. Box/City/State/Zip

I understand that this authorization will be deemed valid unless terminated or revoked in writing by the patient, if of age to consent or emancipated; or, if under the age 18, the patient’s custodial parent or other legal guardian. I further understand that this authorization may be revoked at any time except to the extent that Southern Tier Pediatrics Practice, P.C. has already relied upon it.

I also understand that the information that I have authorized to disclose could potentially be re-disclosed by the person receiving the information, and may no longer be protected under the federal privacy regulations. I further understand that Southern Tier Pediatrics Practice, P.C. is not responsible for any such re-disclosures.

I understand that I have the right to limit the authorization and that nay such restrictions must be sent in writing to Southern Tier Pediatrics Practice, P.C. in writing to the address above.

Signature Date

Printed Name

Relationship to patient:

r Parent of minor

r Guardianship order (attach copy)

r Power of attorney (attach copy)

r Self (Emancipated minor or patient age 18 or over)

r Other (please specify):