Release to Family Members (Connersville 2022)

Release to Family Members

Under the requirements of HIPAA, we are not allowed to give medical or billing information to anyone without patient consent. However, many patients allow family members such as spouses, parents or others to call and request this information. If you wish to have your medical or billing information released to family members, you must sign this form.
This will ONLY give information to family members indicated below.
I, patient's name* born on date of birth* , hereby authorize Centerstone
Health Services to release my medical and/or billing information to the following individuals:
Name*

First NameLast Name
Relationship*
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
I understand I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed.

I understand that information disclosed to any above recipient is no longer protected by federal or state law and may be subject to re-disclosure by the above recipient.

I understand that I have the right to revoke this content in writing.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Signature*

Clear
Should be Empty: