The signing individual, hereinafter referred to as “I” authorize the disclosure of my child’s protected medical and health information (“PHI”) as defined under the privacy regulations promulgated pursuant to the Health Insurance Portability and Accountability Act of 1996 as follows:
Person and Entities Authorized to Disclose My Protected Health Information (PHI)
I hereby authorize any physician, dentist, nurse, or any other medically related healthcare provider at Children’s Dental Hospital to disclose any and all of my child’s PHI as provided under this authorization. I authorize each of the above “Authorized Disclosers” to rely upon a photocopy or facsimile of this authorization and I agree that such photocopy is as valid as the original signed form.
This authorization shall apply to any and all of my child’s health and medical records information, whether or not personally identifiable, or protected under any federal or state confidentially or privacy law.
Expiration of Authorization
This authorization shall remain valid for one (1) year from the date signed.
Revocation of Authorization
I acknowledge and understand that I may revoke the authorization at any time and for any reason. Revocation is to be made effective by notifying the Authorized Discloser and Authorized Recipient in writing, via mail, personal delivery, or facsimile transmission. Notice shall be deemed effective on the first of (i) actual receipt, and (ii) in the case of US mail, within 10 calendar days of mailing (including the date of mailing), and in the case of electronic mail and facsimile, within 3 calendar days of confirmed delivery (including the date of delivery). Any revocation of this authorization shall not apply to the extent that the Authorized Discloser has taken action in reliance upon this authorization prior to receiving notice of my revocation.
