FFM Personal Release

Patient 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 and leave a message on the answering machine regarding my Personal Health Information Okay to call my home but DO NOT leave a message Do not call my home number Okay to email reminders Other
Who may receive information regarding your Protected Health Information that you allow Family First Physicians to speak with?
Spouse:
Significant Other:
Children:
If multiple names, separate by a comma
Parents:
If multiple names, separate by a comma
Friend:
If multiple names, separate by a 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.
Name
Date

Month Day Year
Date
Signature

Clear
Should be Empty:

Patient Release and Communication