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

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