- Welcome Message
- Practice Policy Forms
- Schedule of Exams
- Vaccine & Immunization
- Prescription Refill Form
- Change of Address Form
- Family Medical History Form
- Patient Registration Form
- Records Release Authorization
- Asthma Control Forms
- Patient Consent (18 yrs+)
- Parental Agreement (18 yrs+)
- ADHD (Vanderbilt) Forms
Patient Consent Form
APPOINTMENTS: (248) 856.6300
75 Barclay Circle, Suite 115, Rochester Hills, MI 48307
If the patient is 18 years of age or older, the patient must have a signed written release in his/her chart before any information can be released for the intended purpose or what has been specified on a HIPAA authorization.
According to HIPPA Privacy Regulations, Northeast Pediatrics cannot disclose protected health information unless permitted by the regulations and procedures designed to protect this information.
Permission To Release Medical Information 18 Years & Older
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