Record Release | Century-Airport Pediatrics

Records Release

Authorization for Release of Health Information (Including Alcohol/Drug Treatment and Mental Health Information) and Confidential HIV/AIDS related Information

Patient's Name(Required)

First Last

Patient's Date of Birth(Required)

Patient Identification Number(Required)

Patient's Address(Required)

Street Address Address Line 2 City State ZIP Code

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. I understand that:

1. This authorization may include disclosure of information relating to ALCOHOL and DRUG TREATMENT, MENTAL HEALTH TREATMENT, and CONFIDENTIAL HIV/AIDSRELATED INFORMATION only if I place my initials on the appropriate line in item 8. In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 8, I specifically authorize release of such information to the person(s) indicated in Item 6.

2. With some exceptions, health information once disclosed may be redisclosed by the recipient. If I am authorizing the release of HIV/AIDSrelated, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information or using the disclosed information for any other purpose without my authorization unless permitted to do so under federal or state law. If I experience discrimination because of the release or disclosure of HIV/AIDSrelated information, I may contact the New York State Division of Human Rights at 18883923644. This agency is responsible for protecting my rights.

3. I have the right to revoke this authorization at any time by writing to the provider listed below in Item 5. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

4. Signing this authorization is voluntary. I understand that generally my treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditional upon my authorization of this disclosure. However, I do understand that I may be denied treatment in some circumstances if I do not sign this consent.

Previous Doctor Name, Full Address, Phone and Fax Number(Required)

Century-Airport Pediatrics @ OLV Human Services 790 Ridge Rd, 1st Fl., Lackawanna, NY 14218 P: 716-893-7337 F: 716-893-7699

Transfer of Care

For the following to be included, indicate the specific information to be disclosed and initial below.
Timeframe of records to be released:

Start Date

End Date

All health information (written and oral) to be disclosed, except:(Required)

Records from alcohol/drug treatment programs information

Clinical records from mental health programs* information

HIV/AIDS related information

If not the patient , name of person signing form:(Required)

Authority to sign on behalf of patient:(Required)

Unless previously revoked by me, the specific information below may be disclosed from:

Signature of patient or representative authorized by law(Required)

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Century-Airport Pediatrics

Wellness & Education Since 1995

Century-Airport Pediatrics

Wellness & Education Since 1995

Records Release

Authorization for Release of Health Information (Including Alcohol/Drug Treatment and Mental Health Information) and Confidential HIV/AIDS related Information

Effective 9/14

Updated Office Hours

Records Release

Authorization for Release of Health Information (Including Alcohol/Drug Treatment and Mental Health Information) and Confidential HIV/AIDS­ related Information

Effective 9/14

Updated Office Hours

Authorization for Release of Health Information (Including Alcohol/Drug Treatment and Mental Health Information) and Confidential HIV/AIDS related Information