Patient Communication Form

It is the office policy of this practice not to release confidential medical and health information regarding your treatment to family members or friends. Exceptions include the following; 1) it is the patients parent/legal guardian; 2) other persons authorized by patient; 3) as we may reasonably infer from the circumstances (for example, if you bring a family member or friend into the exam/treatment room, we will assume, unless you object, that the person is entitled to receive information regarding treatment; 4) in emergency situations; 5) as otherwise permitted by the Health Insurance Portability and Accountability Act (HIPAA).

 

If you anticipate that you will need or want your medical or health information to be provided to family members, friends, or caretakers/babysitters, please sign below so we are able to release that information to person listed below.

 

If you DO NOT want any or some of your medical or health information provided to a family member or friend, please circle the “no” response.

 

By signing below, you authorize the following people to receive information regarding your treatment or care. If you wish to add names later on, please let us know and we will have you complete an updated form.

 

You may cancel this authorization to the extent allowed by law. If you do, you understand that the Doctor or Practice may have already released medical or health information after authorization was given.

 

If you wish to cancel or change this agreement, please let us know and we will have you complete an updated form.

Alternative Communication- You are also entitled to specify alternative, reasonable mean of communication if you do not want to be contacted a certain way.