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Home » Contact Us » AUTHORIZATION to RELEASE PROTECTED HEALTH INFORMATION (PHI) to FAMILY AND FRIENDS

AUTHORIZATION to RELEASE PROTECTED HEALTH INFORMATION (PHI) to FAMILY AND FRIENDS

  • I authorize the practice to discuss appointment dates, times, location, medical history, diagnosis, treatment, prognosis, financial, insurance and billing information with those listed below. I understand that my or my child’s healthcare provider will use his/her judgement in sharing this information in order to foster continuity of care. The release of copies of medical records will require a signed HIPAAcompliant (Health Insurance Portability and Accountability Act) authorization. This permission will be considered ongoing until I indicate otherwise in writing.

    PHI MAY BE RELEASED TO THE FOLLOWING INDIVIDUALS

  • The practice staff have my permission to leave messages concerning treatment on my: (Please check all that apply)
  • Date Format: MM slash DD slash YYYY