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Cincinnati Children's Primary Care
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Cincinnati Children's Primary Care
  • About
  • Our Team
    • Specialties
  • Patients
    • Annual Well Child Visits
    • Expectant Parents
    • Prescription Refills
  • Resources
    • Blog
    • Events
    • Forms
    • Health Education and Links
    • Well Care Fact Sheets
    • News
  • Contact
    • Locations

HIPAA Authorization Form

  • Authorization for Use or Disclosure of Information for Purposes (other than TPO) Requested by Physician’s office.
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  • 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).
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  • This field is for validation purposes and should be left unchanged.
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513-336-6700

Mason_PrimaryCare@cchmc.org

If you need to request medical records or form signatures, please email us and we'll respond as soon as possible.

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Cincinnati Children's Liberty Primary Care

7335 Yankee Road,
Suite 100
Liberty Township, OH 45044

Get Directions »

M-F 8 a.m.-5 p.m.
Closed noon-1 p.m. for lunch
Sat. 8 a.m.-noon

Cincinnati Children's Mason Primary Care

9600 Children's Drive, Bldg. D
Mason, OH 45040

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M-Th 8 a.m.-7 p.m.
F 8 a.m.-5 p.m.
Closed noon-1 p.m. for lunch
Sat. 8 a.m.-noon

 

Cincinnati Children's Springdale Primary Care

12061 Sheraton Lane
Cincinnati, OH 45246

Get Directions »

M-F 8 a.m.-5 p.m.
Closed noon-1 p.m. for lunch

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New Well Check and Sick Appointment Announcement!

We want to continue to provide the best care during the COVID-19 pandemic. That’s why we’re now doing all-day well check appointments in our Mason and Liberty Township offices and telehealth appointments for all sick visits. Click the button to learn more!

New Office Hours and Telehealth Information