Release Authorization

Patient's Name*
Date of Birth*
MM
DD
YYYY
Phone*
Social Security #*
Address*
Street AddressCityStateZip Code
Information or records to be used/disclosed/released
- I authorize the release of said information or records TO Southern Tier Pediatrics Practice, P.C. FROM:
Doctor/Facility/Other Party
Phone
Address
Street AddressCityStateZip Code
AND/OR
- I authorize the release of said information or records FROM Southern Tier Pediatrics Practice, P.C. TO:
Doctor/Facility/Other Party
Phone
Address
Street AddressCityStateZip Code
I understand that this authorization will be deemed valid unless terminated or revoked in writing by the patient, if of age to consent or emancipated; or, if under the age 18, the patient’s custodial parent or other legal guardian. I further understand that this authorization may be revoked at any time except to the extent that Southern Tier Pediatrics Practice, P.C. has already relied upon it.

I also understand that the information that I have authorized to disclose could potentially be re-disclosed by the person receiving the information and may no longer be protected under the federal privacy regulations. I further understand that Southern Tier Pediatrics Practice, P.C. is not responsible for any such re-disclosures.

I understand that I have the right to limit the authorization and that any such restrictions must be sent in writing to Southern Tier Pediatrics Practice, P.C. in writing to 1684 Foote Avenue Extension Jamestown, NY 14701.
Printed Name*
Relationship to Patient*
- Parent of minor
- Guardianship order (attach copy)
- Power of attorney (attach copy)
- Self (Emancipated minor or patient age 18 or over)
- Other
Please specify:
Name
This field is for validation purposes and should be left unchanged.

Jamestown Office

Randolph Office

Register Online

Release Authorization

Release Authorization

Navigate

Recent Posts

Search