HIPAA Authorized Individual Form

HIPAA Authorized Individual Form
I authorize Sweetgrass Pediatrics to disclose protected health information for the patient listed below:

Patient Name:

Date of Birth:

This consent gives the listed individuals the authority to discuss and change appointments, bring the child to appointments, discuss clinical information including lab results, prescriptions, financial or insurance details and coordination of care. This consent also includes the authority to revise and edit patient demographic information including, but not limited to, adding and removing authorized users except for those as protected by applicable laws and regulations. With my permission, I hereby authorize the following individual(s):

Name:

Relationship:

Phone Number:

Name:

Relationship:

Phone Number:

Name:

Relationship:

Phone Number:

This authorization shall remain in effect until revoked by the parent, legal guardian, or personal representative (as defined by HIPAA).
This consent does not allow for releasing of medical records or providing portal access. A signed medical release will need to be completed by the parent, legal guardian, or personal representative (as defined by HIPAA) for a copy of medical records.
Signature of Parent, Legal Guardian, Authorized Individual or Personal Representative (as defined by HIPAA):

Print Name:

Date:

Create Signature

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Confirmation