Madisonpodiatrists - Authorization to Discuss Medical Information

AUTHORIZATION TO DISCUSS MEDICAL INFORMATION
I hereby authorize you to use or disclose the specific information described below, only for the purposes and parties also described below.
Description of the specific information to be discussed:

FULL DISCLOSURE Appointment Date/Times Diagnosis X-ray Results Medications Lab Tests/Results Summary of Medical Record Care Plan Billing Other (specify)
Patient Name
Date of Birth

Month Day Year
Date
Information to be given to:
Name
Relationship
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
This authorization shall remain in effect from the date signed below until (please check one):

NO EXPIRATION DATE Specify expiration date/event:
By signing this authorization, I acknowledge that I have read the REVERSE side and I release the above institution(s) and/or person(s) from legal responsibilities or liability that may arise from this act.
Signature of Patient

Clear
Signature of Authorized Person ( Only pertains to minor children or those with Health Care Power of Attorney )

Clear
Date

Month Day Year
Date
Date

Month Day Year
Date
Printed Name of Authorized Person
If signed by a person other than the patient, stated authority to do so below.

Legal Authority Legal Guardian Parent of Minor Next of Kin Power of Attorney
Should be Empty:

AUTHORIZATION TO DISCUSS MEDICAL INFORMATION