|
30 Hempstead Avenue, Suite 248 Rockvile Centre, New York 11570 |
Rockville Centre Pediatrics,
LLP |
Telephone
516-536-3232 Fax 516-536-5626 WWW.RVCPeds.com |
Authorization for completing School/Camp form
I hereby authorize the use and
disclosure of my individually identifiable health information as described
below. I understand that this
authorization is voluntary and is revocable by me in writing, except as described
in our Notice of Privacy Practices. Any
health information disclosed by Rockville Centre Pediatrics, LLP pursuant to
this authorization may be subject to redisclosure by the recipients and may no
longer be protected by the Federal privacy regulations. Rockville Centre
Pediatrics, LLP may not condition treatment, payment, enrollment or eligibility
for benefits on whether you sign this authorization. This will expire in
one year unless otherwise specified or revoked.
Patient
name:__________________________________________________________________________ID
Number: _________ Date___________
Persons/organizations
(School or Camp) who may receive information _____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Purpose of the use or
Disclosure:________________________________________________________________________________
Specific description of the
information to be used or disclosed: (check all that you want disclosed)
|
q Date of birth q Last physical Exam q Current Medical Problems q Immunizations q Scoliosis |
q Relevant past medical history q Lab results such as lead, CBC, Urine q Vision and hearing screen results q Allergies |
Other information to be
included: _______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Please list all medications
you want listed on the form/forms
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Please indicate any information you do not want put onto the form
(e.g. ADHD, depression, anxiety) _______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
This information may be :
q Picked up by
_____________________________________________________________
q Faxed to this
number_______________________________________________________
q Mailed to this address
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
___________________________________________ ________________
Signature of patient or patient’s
representative Date
(Note: This form MUST be completed before
signing.)
If this authorization is signed
by a patient’s representative, please complete the following:
|
________________________________________ Printed name of patient’s
representative: |
________________________________________ Relationship to the
patient: |