Who May We Release Information to- Please specify anyone you authorize our Practice to release information and what type of information we may give out, if requested and approved, about you, your treatment, progress or account. Usually this is a spouse or significant other, Parent or Guardian, Grandparents, adult children or whomever you choose to authorize our Practice and our health care Associates to release information to.
PLEASE PRINT COMPLETE NAME(S) AND LEGAL RELATIONSHIP TO PATIENT.