Due to State and Federal policy relating to privacy it is necessary to have written permission to discuss any personal medical or financial information such as medication, laboratory, radiology, diagnosis and prognosis with anyone other than yourself such as husbands, wives, children, or other relatives or friends. Please list below any person(s) to whom you will allow us to release any medical or financial information. If no one is listed then we will only discuss your medical and financial information with you. Information will still be provided to other health care providers, hospitals, or your insurance companies for the purpose of authorizations or other treatment or specialty referrals. Information to any other entity will need your separate signature specifically authorizing them to access your records.
Name(Required) Relationship(Required) Name Relationship Name Relationship
Patient's Name Date of Birth MM slash DD slash YYYY Today's Date MM slash DD slash YYYY Signature
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