CALL US ON:
43 Sokokis Trl, PO Box 454, East Waterboro, ME 04030
info@wvpkids.com Fax: 207-247-6114
(For General Info and FAQ's)
Transferring Out

Transferring Out

 AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

 (PHI)

This authorization is for use or disclosure of protected health information pertaining to:

I hereby authorize the following health care provider:

  Waterboro Village Pediatrics

  43 Sokokis Trail, PO BOX 454

  East Waterboro, Maine 04030


To release my protected health information to:

Protected health information to be released:

Your specific permission is required to disclose information regarding the following: 

Check box and sign to specify protected health information to be disclosed

If no date is given, this authorization is valid for 30 months  from signature date.

[If mental health facility/agency/program, replace "30 months" with "one year")

  • I understand that I am not required to sign this form and Waterboro Village Pediatrics  will not condition treatment, payment for services, or eligibility for services on whether I sign this form. I understand that my refusal to sign may result in improper diagnosis or treatment, denial of coverage for health benefits or other insurance or other adverse consequences.
  • I understand that PHI released pursuant to this authorization may include records generated by another healthcare provider or facility.
  • I understand that I have the right to access or copy the PHI described in this form by making a written request to the Privacy Officer of this practice

A copying fee may be charged as permitted by law. [If mental health agency/facility/program, add: I have a right to review mental health records prior to the release of those records, with in 3 working days of my request"

  • I understand that I have the right to withdraw my authorization at any time except to the extent that action has been taken in reliance on this authorization. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to the Privacy Officer at [enter practice name]. I understand that revocation may be the basis for denial of health benefits or other insurance coverage or benefits.
  • I understand that PHI used or disclosed pursuant to this authorization may be re-disclosed by the recipient and no longer be protected by confidentiality laws.
  • I understand that PHI that includes alcohol or drug program information protected by federal law will require notice to the person receiving the information that it may not be shown to or shared with others without my express written permission.
  • I understand that I have a right to receive a copy of this authorization.
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