Patient Authorization

1

Patient Name* This field is required.

First Name

Last Name

2

Patient Date of Birth

XX/XX/XXXX

3

We cannot discuss a patient's health care with any individual (including spouses or parents of children over 18) unless it is authorized by the patient or legal guardian. Would you like to authorize the release of your health information to another individual?* This field is required.

YESNO

4

Please type the name of the individual and their relationship to you.

Name

Relationship to patient

5

Would you like to add another individual?

YESNO

6

Please type the name of the individual and their relationship to you.

Name

Relationship to patient

7

Would you like to add another individual?

YESNO

8

Please type the name of the individual and their relationship to you.

Name

Relationship to patient

9

Would you like to add another individual?

YESNO

10

Please type the name of the individual and their relationship to you.

Name

Relationship to patient

11

It is completely your decision whether or not to sign this authorization form. We will not refuse to treat you if you choose not to sign this authorization. If you sign this authorization, you may revoke it at any time by contacting in writing, FAX or email the Privacy Official noted in the Notice of Privacy Practices.

When your health information is disclosed under this authorization, the recipient has no duty to protect its confidentiality. The recipient may re-disclose the information as he/she wishes.

12

Attestation

I have read and understand this form. I am signing it voluntarily.

13

Please click on if you will be signing as the patient or as a representative of the patient.

PatientRepresentative

14

What is your relationship to the patient?Parent, Caregiver, etc.

15

Signature

Clear