Sherry Nussbaum, M.D., P.A.
1008 North Bowen Road
Arlington, TX 76012
(817) 861-2288
www.sherrynussbaummd.com

Release of Protected Health Information

Information authorized to be released:
(Please note: 24-Hour notice required) *
Please release my protected health information to the following person/entity:
(You may make this out to yourself if you are the parent/legal guardian)
Please provide a copy of a valid Driver's License or valid ID.

The reason or purpose for the release of this information is as follows: *
 
This authorization shall be in effect until the child's 18th birthday unless written notice is received in our office from the parent/guardian stating otherwise.

I understand that I have the right to revoke this authorization, in writing, at any time by sending a written notification to the staff at this practice:
1008 North Bowen Road
Arlington, TX 76012
Ph: (817) 861-228
Fax: (817) 460-1595

I understand that a revocation is not effective to the extent that the practice has relied on this authorization in its actions.  Also, a revocation is not effective if this authorization was obtained as a condition of obtaining insurance coverage, as other law provides the insurer with the right to contest a claim under the policy or the policy itself. 

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 HIPPA privacy regulations.

This practice will not condition my child's treatment, payment, and enrollment in health plan, or eligibility for benefits on whether I provide authorization for the requested use or disclosure.
 *
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