Parents/Guardians: Please sign the following form after reviewing Kent Station Pharmacy’s Notice of Privacy practices, which can be found at www.kentstationpharmacy.com.
Kent Station Pharmacy is covered by the medical information privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (generally called “HIPAA”) and its Regulations. As a result, we are required to comply with HIPAA and the Regulations in the use and disclosure of health information by which our patients can be individually identified. We are also required under Section 164.520 to give our patients this notice (in paper or electronically as the patient wishes) of our legal duties and privacy practices concerning their Protected Health Information, and also to tell our patients about their rights under HIPAA and the Regulations. If you have any questions about our policies, please contact us directly. We are required by this Act to request your signature upon receipt of this document. Please sign your first and last name clearly on the line below. If your child is 18 or older, he or she may sign as an adult.
I have reviewed a copy of the Kent Station Pharmacy Privacy Notice.
Signature: _____________________________
Date: _____________________
I authorize the release of my medical/prescription information to my parent/guardian (for students over 18 years old).
Signature: ____________________________________________
Date: _________________________________________________
Please return a signed copy of this document to:
Pharmacist
Kent Station Pharmacy
38 North Main Street/PO Box 632
Kent, CT 06757