Peter S. Waldstein, M.D., F.A.A.P.
A Medical Corporation
Julia White, M.D., F.A.A.P.
Patient Authorization for Use and Disclosure of Protected Health Information
By signing, I authorize the medical office of Dr. Waldstein and Dr. White to use and/or disclose certain
protected health information about my child.
This authorization permits the office to use and/or disclose the following individually identifiable health
information about dates of services, diagnoses, prescriptions, allergies, and vaccinations.
This information will be used or disclosed for the following purposes:
At the request of the parent or guardian to be released to Other Physicians, Medical Insurance Companies,
School, Camps, and other disclosures specifically requested by the parent or guardian.
The purpose(s) is/are provided so that I can make an informed decision whether to allow the release of
information.
This practice will not receive payment or any other compensation from a third party in exchange for using
or disclosing the PHI.
I do not have to sign this authorization in order to receive treatment. I have the right to refuse to sign this
authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to
redisclosure by the recipient and may no longer be protected by the federal HIPPAA Privacy Laws. I have
the right to revoke this authorization in writing except to the extent that the practice has acted in reliance
upon this authorization. My written revocation must be submitted to the office at:
150 N. Robertson Blvd., suite # 307
Beverly Hills, CA 90211
tel # 310-659-8687 fax # 310-659-2420
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Signature of Parent or Legal Guardian
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Relationship to Patient
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Patient’s Name
____________________________
Date