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 _____________________________________________________________________________________________________

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Purpose of the use or Disclosure:________________________________________________________________________________

Specific description of the information to be used or disclosed: (check all that you want disclosed)

Other information to be included: _______________________________________________________________________________________________________

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Please list all medications you want listed on the form/forms

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?/span>Please indicate any information you do not want put onto the form (e.g. ADHD, depression, anxiety) _______________________________________________________________________________________________________

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This information may be :

q      Picked up by _____________________________________________________________

q      Faxed to this number_______________________________________________________

q      Mailed to this address

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___________________________________________��������������������������������?________________

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:

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