Authorization to Disclose Protected Health Information Form

Yogman Pediatric Associates

Dr. Michael Yogman, Dr. Laura Need, Dr. Marni Roitfarb
575 Mt. Auburn St. Suite 202, Cambridge, MA 02138

 

 

 

Patient Name: ___________________________      Date of Birth: _________

 

I hereby authorize YOGMAN PEDIATRIC ASSOCIATES  to disclose my protected health information to:

 

NAME ____________________________________________

 

RELATIONSHIP ____________________________________

 

NAME ___________________________________________

 

RELATIONSHIP ____________________________________

 

Reason for Request

[ ]18 years and older Release of PHI to Parent


 

Right to Revoke:I understand that I have the right to revoke this authorization at any time. I understand that my revocation must be in writing. And I understand that the revocation will not apply to information already release based on this authorization.

 

______________________________________                

Signature of Patient                                                                

 

________________

Date

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