Medical Records Form

 Patient Information:
Patient DOB:

I hereby authorize you to use or disclose the specific information described below, only for the purpose and parties also described below.

Description of the specific information to be used or disclosed:

Person or entity requesting the information and authorized to make the requested use or disclosure: Atlanta Pediatric Partners, P.C. 4579 S. Cobb Dr SE, Suite 300, Smyrna GA 30080

Continuation of Medical Care This authorization shall remain in effect from the date signed below and for up to 90 days thereafter.

I understand that:

  • I may inspect or copy the protected health information to be used or disclosed
  • I may revoke this authorization in writing by contacting your office at the address above, attention Privacy Officer
  • Information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer be protected by HIPAA
  • I may refuse to sign this authorization and that you will not condition treatment or payment on me providing this authorization (except to the extent that the authorization is for the research-related treatment)
  • If this line is checked, I understand that you will receive compensation from a third party for the use or disclosure of my information.