HIPAA Privacy Release Form (Infant)
HIPAA Privacy Release Form (Infant)
Parent/Guardian Name completing the form
Parent/Guardian Name completing the form
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First
Last
Minor's Name
Minor's Name
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First
Last
Infant's Date of Birth
Infant's Date of Birth
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/
MM
/
DD
YYYY
Parent/Guardian's Phone Number
Parent/Guardian's Phone Number
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This authorization allows MiLK, LLC and it's representatives to communicate with the minor's 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 the breastfeeding caregiver and the breastfeeding minor.
By signing this form, you are providing authorization to disclose protected health information in regards to the minor.
Information that may be disclosed may include, but not limited to:
Information regarding the minor's health
Caregiver's concerns, objectives, plans for care, and recommendations made to the caregiver
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.