AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHI)
Patient Name: (Last, First, Middle) ____________________________________				DOB: _____________
Address:_____________________________________________				SSN: _____________
City: ________________		State: _________	Zip Code: ____________
ENTITY RECEIVING THE PHI:		PROVIDER AUTHORIZED TO RELEASE THE PHI:
The Pediatric Clinic 888 Tara Boulevard Baton Rouge, Louisiana  70806 Telephone: 225-926-4400 Fax: 225-926-4409		Name: _________________________________ Address: ____________________________________ City:_____________      State: ___________    Zip Code: ______ Attention: ______________________________
This authorization will expire on the following date or event: Date: _____________________            Event: ___________________________________________________
Purpose of this disclosure: Transferring records to another physician       REASON: _____________________  Daycare/School    Records to a Specialist    Insurance Purpose    Other: ___________________________
PHI AND DATES OF PHI AUTHORIZED FOR USE OR DISCLOSURE
Description			Start Date	End Date
All PHI in the Record			________________	________________
Progress Notes			________________	________________
Laboratory Notes			________________	________________
X-Ray Tests/Reports			________________	________________
History and Physical Examination			________________	________________
Discharge Summary			________________	________________
Consultation Reports			________________	________________
Itemized Billing Statement			________________	________________
Other: _______________________			________________	________________
The following information will be released when included in the above information unless you indicate otherwise: AIDS or HIV test results                                                                               Psychiatric or Mental care/treatment Alcohol, drug, or substance abuse treatment                                     Other: ________________________
I UNDERSTAND THAT:      1. I may refuse to sign this authorization and it is strictly voluntary.      2. My treatment, payment, enrollment, or eligibility for benefits may not be conditioned on signing this           authorization.      3. I may revoke this authorization at any time in writing to the provider authorized to release the protected           health information, but if I do, it will not have any affect on any actions taken prior to receiving the           revocation.      4. If the requester or receiver is not a health plan or health care provider, the released information may no           longer be protected by federal privacy regulations and may be disclosed.      5. I have the right to receive a copy of this form after I sign it.
Signature of Patient: _____________________________________________				Date: _____________
Signature of Patient's Representative : ________________________________				Date: _____________
(if necessary)
Personal Representative's Relationship to Patient: _______________________________________________
Reason for transfer: ________________________________________________________