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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