HIPAA Release Form for School/Daycare

WCP - HIPAA Release Form for School/Daycare

Version: 1
Created: 9/27/2018
The screens you are filling out will be billed to your insurance. We recommend these screens as they follow the best practice as set forth by the American Academy of Pediatrics.
By signing this form, I authorize Whole Child Pediatrics to release and receive, whether oral or recorded in any form or medium, the below information concerning my child’s confidential health information.
Patient Name Patient Name * First Last
Patient DOB Patient DOB * / MM / DD YYYY