HIPAA Privacy Release Form (Parent)
HIPAA Privacy Release Form (Parent)
Nursing Parent's name
Nursing Parent's name
*
First
Last
Nursing Parent's date of birth
Nursing Parent's date of birth
/
MM
/
DD
YYYY
Phone
Phone
*
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This authorization allows MiLK, LLC and it's representatives to communicate with your medical provider and other support teams as needed. Communication with support staff and medical providers is strongly encouraged by Healthy Children Project, the certifying body for Certified Lactation Counselors as a means to provide the best counseling possible for you and your baby's health.
By signing this form, you are providing authorization to disclose protected health information.
Information that may be disclosed may include, but not limited to:
Information regarding your infant's health
Personal concerns, objectives, plans for care, and recommendations made to you.
Mental Health
HIV Status or Communicable Diseases
Alcohol or drug abuse.
You may revoke this authorization by emailing help@milk.solutions
This authorization expires 2 years from date of signature.
*
Draw
or
Type
I understand this is a legal representation of my signature.
Clear
Full Name
I understand this is a legal representation of my signature.