Personal Release

Family First Physicians

2345 E. Southern Ave. Ste 101 Mesa, Az 85204
Personal Release and Communication
Patient Name
Date of Birth

Month Day Year
Date
There are occasions when Family First Physicians may have to contact you to discuss Confidential Protected Health Information. Please let us know how you would like to get this information to you:
Okay to call my home/cell phone and leave a detailed message regarding my Personal Health Information Okay to call my home/cell but NO NOT leave a message Okay to email reminders Okay to email reminders if unable to reach by phone
Who may receive information regarding your Protected Health Information that you allow Family First Physicians to speak with?
Spouse- Name:
Significant Other- Name:
Children- Name(s):
If multiple names, separate by comma
Parent- Name(s):
If multiple names, separate by comma
Friend- Name(s):
If multiple names, separate by comma
I have received a copy of Notice of Privacy Practices from Family First Physicians, PLLC, and authorize the above list of persons' who many receive information regarding my Protected Health Information. I may revoke this any time by giving written notification to Family First Physicians, PLLC.
Date

Month Day Year
Date
Signature

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Family First Physicians