2-Hole 1/4 2 3/4 c-to-c CHILDREN’S HEALTHCARE OF ATLANTA AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION 22035-01 3-Hole 1/4 4 1/4 c-to-c PRINT PATIENT’S Full Name PRINT name of Parent/Legal Guardian, or Patient (if 18 years of age or older) DAY Phone Number & Area Code E-mail Address: heck ( 9 ) one. I am the 9 Patient (must be 18 years of age or older) 9 Parent or 9 Legal Guardian with custody C (please provide proof of custodianship) 9 Call to pick up records PATIENT’S Date of Birth OR DAY Phone Number & Area Code 9 Mail records to: PRINT Name of Individual(s) or Agency PRINT (Street Address or Box Number) PRINT (City, State, & Zip Code) I place no limitations on history or illness (including HIV and/or AIDS, genetic, drug dependency or psychiatric information) or diagnostic and therapeutic information, including any treatment for alcohol, drug abuse, or psychiatric disorders.  I authorize the inspection of the above information by the above named agency/person and/or to the furnishing of a photostat or other copies. I understand that unless otherwise limited by state or federal regulation, I may withdraw this consent at any time by submitting my withdrawal request in writing. The withdrawal of this authorization does not affect any health information disclosed prior to Children’s Healthcare of Atlanta receiving a written notice of withdrawal.  I hereby release Children’s Healthcare of Atlanta and its officers, directors, agents, and employees from any and all liabilities, responsibilities, damages, losses, and claims which might arise from the release of the information authorized above.  In furtherance of this authorization, I do hereby waive all provisions of the law and privileges related to the disclosures hereby authorized. I hereby acknowledge that I have read (or had someone read to me) the above statements, and that I fully understand the above statements, and do expressly and voluntarily authorize the disclosure of this medical information to the individual or agency named above. Check (3) treatment location(s) from which you would like records released: 9 Children’s at Scottish Rite 9 Children’s at Egleston 9 Children’s at Hughes Spalding 9 Marcus Autism Center 9 Satellite Facility (list locations): 9 All of these locations 9 Children’s Physician Group Specialty Services (list clinic): THE FOLLOWING INFORMATION IS TO BE RELEASED Check (3) Correct Document(s) 9 ABSTRACT: This option includes; problem list, allergies, immunizations, autopsy report, clinic notes, consultations, discharge/transfer summary, emergency room record, face sheet, history & physical exam, laboratory reports, neuropsychological reports, operative reports, pathology, psychosocial notes, radiology reports, rehabilitation records, therapy notes, ECHO reports, & medications. 9 ENTIRE RECORD WITH NURSING FLOWSHEETS 9 EMERGENCY ROOM RECORD 9 ENTIRE RECORD WITHOUT NURSING FLOWSHEETS 9 OTHERS (Specify): RECORDS DISTRIBUTED: 9 CD (when available*) 9 PAPER * When choosing to have records released on CD, your total cost will be reduced to 50% of the total per page cost of your request. Applicable Dates/Encounters (Specify) The purpose for which this release is being requested is: 9 Continuing Medical Care 9 Insurance Reimbursement 9 Other (Specify) Undeclared (at the request of the below signed) 9 Legal Action/Review Any disclosure of medical information by the recipient(s) is prohibited except when implicit in the purpose of this authorization. This authorization expires ________________________ (insert applicable date or event or insert “no expiration designated”) or in 6 months (12 months for school requests), whichever is shorter, and no further use/disclosures as described above may be made after the expiration. Authorizations apply only for medical records for specified treatment dates prior to and on the date of signature, unless otherwise specified. Specified exceptions for future-dated releases are: 9 School 9 Other Signature: Date: INTERNAL USE ONLY 9 Faxed 9 Mailed 22035-01 (Rev. 6/2013) 9 Pick-up/Called 9 CD 9 Date 9 PAPER Initials 2-Hole 1/4 2 3/4 c-to-c CHILDREN’S HEALTHCARE OF ATLANTA AUTHORIZATION TO OBTAIN MEDICAL, PSYCHOLOGICAL, 22035-01 OR EDUCATIONAL INFORMATION 9 PARENT 9 LEGAL GUARDIAN Check (3) Correct One PRINT name of Parent/Legal Guardian, or Patient (if 18 years of age or older) PRINT PATIENT’S FULL NAME PATIENT’S DATE OF BIRTH 9 PATIENT MEDICAL RECORD NUMBER ACKNOWLEDGE THAT THIS JOINT AUTHORIZATION GRANTED BY ME TO ALLOW THE AGENCY(IES) NAMED BELOW TO OBTAIN MEDICAL, PSYCHOLOGICAL OR EDUCATIONAL INFORMATION. I DO HEREBY AUTHORIZE CHILDREN’S HEALTHCARE OF ATLANTA TO OBTAIN AND/OR EXCHANGE WRITTEN AND VERBAL INFORMATION FOR THE PURPOSE OF MEDICAL, PSYCHOLOGICAL, AND/OR EDUCATIONAL EVALUATION. All information I hereby authorize to be obtained from the agency(ies) named below will be held in strict confidence. I place no limitations on history or illness (including HIV and/or AIDS) or diagnostic and therapeutic information, including any treatment for alcohol, drug abuse, or psychiatric disorders. I consent to the inspection of the information by the below named agency/person and/or to the furnishing of a photostat or other copies. I understand that unless otherwise limited by state or federal regulation, I may withdraw this consent at any time by submitting my withdrawal request in writing. I also understand that this consent will not expire until the patient or his/her legal representative in writing withdraws it. This withdrawal of the authorization does not affect any health information disclosed prior to Children’s Healthcare of Atlanta receipt of written notice of withdrawal. I hereby release Children’s Healthcare of Atlanta and its officers, directors, agents, and employees from any and all liabilities, responsibilities, damages, losses, and claims which might arise from the release of the information authorized above. In furtherance of this authorization, I do hereby waive all provisions of the law and privileges related to the disclosures hereby authorized. I hereby acknowledge that I have read (or had someone read to me) the above statements, and that I fully understand the above statements, and do expressly and voluntarily consent to the disclosure of this medical, psychological, or educational information to the person (s) or agency(s) listed below. INFORMATION TO BE OBTAINED FROM: 9 SCHOOL: (Name, Address, & Phone) 9 PHYSICIAN/HOSPITAL: (Name, Address, & Phone) 9 MENTAL HEALTH PROFESSIONALS: (Name, Address, & Phone) 9 LAW ENFORCEMENT 9 DFCS (Name, Address, & Phone) (Name, Address, & Phone) 9 OTHER: (County) (Name, Address, & Phone) LIST SPECIFIC INFORMATION APPROVED FOR RELEASE: This authorization expires (insert applicable date or event or insert “no expiration designated”) or in 6 months, whichever is shorter, and no further use/disclosures as described above may be made after each expiration. Authorizations apply only for medical records for specified treatment dates prior to and on the date of signature. SIGNATURE (Parent, Guardian, or Patient (if patient is 18 years of age or older) SIGNATURE (Children’s Healthcare of Atlanta Representative) DATE DATE MAILTO CHILDREN’S HEALTHCARE OF ATLANTA CHILDREN’S HEALTHCARE OF ATLANTA CHILDREN’S HEALTHCARE OF ATLANTA CHILDREN’S HEALTHCARE OF ATLANTA CHILDREN’S HEALTHCARE OF ATLANTA AT EGLESTON ATTN: Health Information Services 1405 Clifton Road, NE Atlanta, GA 30322 ATTN: 22035-01 (Rev. 6/2013) AT SCOTTISH RITE ATTN: Health Information Services 1001 Johnson Ferry Road, NE Atlanta, GA 30342 ATTN: AT MARCUS AUTISM CENTER ATTN: Health Information Services 1920 Briarcliff Road Atlanta, GA 30329 ATTN: AT HUGHES SPALDING ATTN: Health Information Services 35 Jesse Hill Jr. Drive Atlanta, GA 30303 ATTN: SPECIALTY SERVICES ATTN: Health Information Services 2015 Uppergate Dr. Atlanta, GA 30322 ATTN: 3-Hole 1/4 4 1/4 c-to-c I,