1.
Patient's Name: ____________________________________ Date of Birth:____________________
2.
Patient's Name: ____________________________________ Date of Birth:____________________
3.
Patient's Name: ____________________________________ Date of Birth:____________________
4.
Patient's Name: ____________________________________ Date of Birth:____________________
Name:
Address:
Fax:
I authorize copies of the Medical Records for the following period:
______________ TO _______________
I do
I do not
Reason for transfer/disclosure:
If transferring for insurance reasons, please specify which insurance company:
Signature of Parent/Guardian OR Patient if over 18:
Date:
I, _________________________________________________(Guardian/Patient), understand that Pediatric Associates of Savannah,
PC is authorized by me to use, release, and/or disclose the Protected Health Information (PHI) as described below. I understand the
information disclosed pursuant to this Authorization may be subject to re-disclosure by the recipient and no longer protected by the HIPAA
Privacy Rule
Pediatric Associates of Savannah, PC
4600 Waters Ave., Suite 100
Savannah, GA 31404-6273
Office: (912) 355-2462
Fax: (912) 353-1836
Authorize release of information related to psychological assessments (i.e. ADHD testing, therapy), AIDS/
HIV or any other communicable diseases, psychiatric care, and/or treatment for alcohol and/or drug
abuse.
I authorize the following information to be sent to the above address: (Check all that apply)
History and Physical Examination Lab, X-Ray, and other reports
Reports from other Physicians and hospitals Other (Please Specify)
The following information should not be released (Please Specify):
I hereby authorize disclosure of the health information for the above named patient. I understand that I may cancel this request with written
notification but that it will not effect any information released prior to notification of cancellation. I understand that the information used or
disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by
federal regulations. I understand that the medical provider to whom this authorization is furnished may not condition its treatment of me on
whether or not I sign the authorization. This authorization will expire 10 years from today's date unless otherwise specified. I understand that I
may REVOKE this authorization at any time.
Month Day Year Month Day Year
Fax: 912.353.1836
Michael D. De Mauro, MD, FAAP
Diane R. Savage-Pedigo, MD, FAAP
Paul L. Nave, MD, FAAP
Ben Spitalnick, MD, MBA, FAAP
Steve Hobby, MD, CPC, FAAP
Adria H. Wilkes, MD, FAAP
Release To From Release To From
Chintak Patel, MD, FAAP
Brandy Gheesling
,
M
D,
CLC
,
FAAP
Christopher C. Rogers, MD, FAAP
Carly Ryan, MD, FAAP
Giselle M. Rosinia, MD, FAAP
click to sign
signature
click to edit
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