Please Note: this is an electronic signature and by typing your name it is an authorized signature. Also, if you are on a touch screen, tablet or mobile phone, you can sign your name in the field using your finger or mouse.
Are you the Parent/Legally Recognized Representative of Patient?
Select "Yes" ONLY if you are the Parent/Legally Recognized Representative of the patient.
* This Authorization is not valid for use or disclosure of psychotherapy notes.
** The term "genetic tests" means only those tests which determine your future chances of developing a disease, not test done to diagnose a current condition or problem. This includes information related to the testing of embryos created during IVF.
*** Only applicable to records that are created by an "individual or entity who holds itself out as providing alcohol or drug abuse diagnosis, treatment or referral for
treatment" (42 CFR Part 2). Does not include records created or maintained by a general medical facility.
Term: This Authorization will remain in effect until Essex County OB/GYN Associates Inc fulfills this request.
Revocation: I understand that I may revoke this Authorization at any time by requesting it of Essex County OB/GYN Associates Inc in writing at the address listed below.
The revocation will be effective immediately upon Essex County OB/GYN Associates Inc receipt of my written notice. I understand that the revocation will not have any effect on any action taken by Essex County OB/GYN Associates Inc in reliance on this Authorization before it received my written notice of revocation.
Effect on Treatment: I understand that I may refuse to sign this Authorization for any reason and that such refusal will not affect the commencement, continuation or quality of my treatment at Essex County OB/GYN Associates Inc.
Potential for Redisclosure: I understand that the person receiving my Protected Health Information may not be required to comply with federal and state Privacy laws, and my Protected Health Information may no longer be protected by the applicable state and federal law once it is disclosed by Essex County OB/GYN Associates Inc.
Access: I understand that in certain circumstances Essex County OB/GYN Associates Inc. has the right to deny me access to all or portions of my Protected Health Information and must notify me in writing of any such denials.
COPY FEE: For Patient record requests - Pursuant to HIPAA 45 CFR, 164.524, we reserve the right to charge a reasonable cost‐based fee for producing and mailing the copies. If you want the entire medical record or more than the two year abstract, the rate will increase proportionately based on the cost. For all other release of information requests, the applicable US state statute governing fees for medical records will be applied.