The Blast 2024 - Tribute Walk - PHI

Authorization to Obtain and/or Release Protected Health Information (“PHI”) Form

This form, if signed, will authorize Cook Children's Health Care System (“CCHCS”) to obtain and/or release certain health information about the person named below. All items must be completed and the authorization signed and dated by an authorized person to be valid. I may refuse to sign this authorization and I understand that CCHCS may not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.

Question Title

* Parent or Legal Guardian Information

Full Name

Email Address

Phone Number

I authorize CCHCS and/or Cook Children's Health Foundation to obtain and/or release health information, as described below, relating to:

Question Title

* Patient Name

Question Title

* Patient Date of Birth (mm/dd/yyyy)

Patient information is needed for: Marketing

The information may be released to attendees of the fundraising event known as "The Blast." The specific information to be released is the information on the Tribute Walk sign.

I understand and acknowledge the following statements: I may be asked to show proof that I have the authority to sign this authorization. I may be charged a fee for any copies of my medical records or my child’s medical records in accordance with federal and state regulations. I have the right to revoke this authorization at any time. Revocation must be made in writing to: Cook Children's Health Care System, Health Information Management Department, 801 7th Avenue, Fort Worth, Texas 76104. My revocation will not apply to information that has already been disclosed in response to this authorization. After the above medical information is released, it may be re-released by the recipient and the information may no longer be protected by federal privacy laws or regulations.

Question Title

* REVOCATION: Unless otherwise revoked in writing, this authorization is valid until the following specific date (optional):

Revocation Date

Date

For patients under the age of 18 at the time this authorization is signed, if no expiration date is indicated, this authorization is valid until the patient’s 18th birthday. For patients who are 18 years of age or older at the time this authorization is signed, if no expiration date is indicated, this authorization will expire 2 years from the date this form is signed.

Question Title

* I certify that I am the parent or legal guardian of the aboved named patient.

Yes