Pediatric HIPAA Authorization Form
Patient Information
Patient Name
Date of Birth
Parent/Guardian Name
Relationship to Patient
Phone Number
Email Address
Authorization
I authorize the use and disclosure of the medical information described below:
Information to be released (check all that apply):
Medical Records
Immunization Records
Lab Results
Other
If Other, specify:
Purpose of Disclosure
Release To (Name of person or organization authorized to receive information):
Phone Number
Address
Expiration Date or Event
Additional Information/Restrictions
Signature & Date
Signature of Parent/Guardian
Date