Release of Medical Information and Assignment of Benefits
I authorize Pediatric Health Associates, Ltd. to release any medical information and copies of any medical records necessary to process a related claim and to request payment of benefits directly to Pediatric Health Associates, Ltd.
I also authorize Pediatric Health Associates, Ltd. to release to my current and former insurance plans and any other treating or consulting physicians, other health care professionals, laboratories, and healthcare facilities, any medical information and copies of any medical records requested by those parties for purposes including but not restricted to:
- medical consultations and office visits
- lab/medical testing
- insurance chart reviews
I also understand that de-identified patient information may be given to researchers that we are working with. Medical information will only be released to the parents/legal guardian of patients 17 years of age and under and directly to patients 18 years of age and older. Medical information will not be released to any other parties, unless legal documentation has been provided to Pediatric Health Associates, Ltd.