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 INDIVIDUALS1.2.3.4.o The practice staff have my permission to share my or my child’s personal health information with family members or others who are in the room with me/us during the appointment.YesNoThe practice staff have my permission to leave messages concerning treatment on my: (Please check all that apply) Home Voice Mail/Answering Machine Home Phone Number Cell Phone Cell Phone Number Work Voice Mail Work Phone Number NO INFORMATION; I do not authorize the release of any verbal information (other than appointment reminders to the number(s) that I have provided. Name of Patient First Last Name of Authorized RepresentativeEvidence of authority must be provided and on file with the practice; Authorized Representative’s authority to act on the patient’s behalf:Parent/Legal GuardianPower of AttorneyPatient/Authorized Representative SignatureDate Date Format: MM slash DD slash YYYY
