{"content":[{"text":"HIPAA Authorization for Release of Information \n Section A : Name and Locations \n I hereby authorize the disclosure of my individually identifiable health information as described below. I understand \n that this authorization is voluntary. I understand that if the organization authorized to receive the information is not a \n health plan or health care provider; the released information may no longer be protected by federal privacy \n regulations. \n Patient name:_____________________________ Date of Birth:_____/_____/_____","bbox":{"left":0.117686,"top":0.132706,"width":0.763256,"height":0.147789}},{"text":"_____________________________","bbox":{"left":0.230425,"top":0.294359,"width":0.28436300000000003,"height":0.020984999999999976}},{"text":"Date of Birth:_____/_____/_____","bbox":{"left":0.544199,"top":0.294359,"width":0.274432,"height":0.020984999999999976}},{"text":"_____________________________ Date of Birth:_____/_____/_____ \n Practice providing the information: Please send the information to: \n Alabama Pediatrics _______________________________ \n 2815 Independence Drive Name \n Birmingham, Alabama 35209 _______________________________ \n Street \n _______________________________ \n City, State, Zip code","bbox":{"left":0.117686,"top":0.329245,"width":0.7099880000000001,"height":0.17659099999999994}},{"text":"Section B: Must be completed for all authorizations","bbox":{"left":0.117686,"top":0.520912,"width":0.430765,"height":0.02098500000000003}},{"text":"1. Please send the:","bbox":{"left":0.117686,"top":0.555786,"width":0.12046399999999997,"height":0.016776000000000013}},{"text":"___Entire medical record.","bbox":{"left":0.254571,"top":0.555786,"width":0.17011800000000005,"height":0.016776000000000013}},{"text":"___Last 3 years","bbox":{"left":0.440947,"top":0.555786,"width":0.10308300000000004,"height":0.016776000000000013}},{"text":"___Last 5 years","bbox":{"left":0.560386,"top":0.555786,"width":0.10326199999999985,"height":0.016776000000000013}},{"text":"2. Other limitations (please specify, if any):___________________________________","bbox":{"left":0.117686,"top":0.584876,"width":0.5704370000000001,"height":0.016776000000000013}},{"text":"3. Purpose of disclosing the information:","bbox":{"left":0.117686,"top":0.613816,"width":0.26636499999999996,"height":0.016776000000000013}},{"text":"__Insurance __Attorney__Doctor__Personal___Moving","bbox":{"left":0.392253,"top":0.613816,"width":0.36927100000000007,"height":0.016776000000000013}},{"text":"Section C: Patients rights and signature \n I understand that my records may contain information regarding the diagnosis and treatment of all my medical \n conditions in the possession of the practice indicated above and may include confidential information such as that \n about the diagnosis of treatment of conditions such as HIV/AIDS, STDS, drug/and or alcohol abuse and \n psychological conditions. I give my specific authorization for these records to be released. I understand that I do not \n have to sign this authorization in order to obtain health care benefits (treatment,payment, or enrollment). I may \n revoke this authorization at any time by writing to the medical practice at the address indicated above. I understand \n that once the health information that I have authorized to be disclosed reaches the indicated recipient, that other \n persons or organizations my re-disclose it, at which time may no longer be protected under Privacy Laws. A \n photocopy of this authorization is to be considered as valid as the signed original document. I understand that I must \n provide proof of identity at the time of signature.","bbox":{"left":0.117686,"top":0.642906,"width":0.762005,"height":0.16484500000000002}},{"text":"____________________________________________ \n Signature of patient or patient’s representative","bbox":{"left":0.117686,"top":0.822505,"width":0.43136599999999997,"height":0.03884900000000002}},{"text":"____/____/_____ \n Date","bbox":{"left":0.647173,"top":0.822505,"width":0.13841199999999998,"height":0.03884900000000002}},{"text":"THIS AUTHORIZATION IS VALID FOR (5) YEARS UNLESS ANOTHER DURATION IS SPECIFIED \n UNDER SECTION B(2). \n Printed name of patients representative:_____________________________________ \n Relationship to the patient:________________________________________________","bbox":{"left":0.117686,"top":0.875628,"width":0.7407180000000001,"height":0.07859900000000009}}],"images_bbox":[{"left":0.385131,"top":0.060606,"width":0.229575,"height":0.059848}],"images_bbox_not_text_overlap":[{"left":0.385131,"top":0.060606,"width":0.229575,"height":0.059848}]}