HIPAA Authorization Form Authorization for Use or Disclosure of Information for Purposes (other than TPO) Requested by Physician’s office.Name First Last Patient Name First Last Patient Date of Birth MM slash DD slash YYYY I, (Name) hereby authorize Cincinnati Children's to: use and/or disclose any protected health information (e.g. immunization records, lab reports, child’s health status, etc.) to the following entities via telephone/fax/mail: School/daycare/babysitter Insurance companies Other health care providers Any exclusions? Yes No Exclusions:Okay to leave messages at home? Yes No Okay to leave messages at work? Yes No This authorization shall be in force and effect for 365 days from today’s date at which time this authorization to use or disclose this protected health information expires. THIS DOCUMENT APPLIES TO ALL FAMILY MEMBERS UNDER OUR CARE UNLESS OTHERWISE DESIGNATED BY THE RESPONSIBLE PARTY. I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to Cincinnati Children's. I understand that a revocation is not effective to the extent that Cincinnati Children's has relied on the use or disclosure of the protected health information. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. Cincinnati Children's will no condition my treatment, payment, enrollment in a health plan or eligibility for benefits (if applicable) on whether I provide authorization for the requested use or disclosure. I understand that I have the right to: • Inspect or copy the protected health information to be used or disclosed as permitted under federal law (or state law to the extent the state law provides greater access rights) • Refuse to sign this authorization The use or disclosure requested under this authorization may result in direct or indirect remuneration to Cincinnati Children's from a third party (if applicable).Electronic Signature of Patient or Responsible Party First Last Name of Responsible Party First Last Date MM slash DD slash YYYY Relationship to Patients CAPTCHAEmailThis field is for validation purposes and should be left unchanged.