Authorization to release medical information to Individuals / Family members

Patient's name: *

In accordance with Federal government privacy rules implemented through the Healthcare Portability Act of 1996 (HIPAA), in order for your physician or staff of the practice to discuss your condition with members of your family or other individuals that you designate, we must obtain your authorization prior to doing so. In the event of a critical episode or if you are unable to give authorization due to the severity of medical condition, the stipulate these rules may be waived. *

I authorize the Practice to verbally release any or all information concerning my medical care to the following individuals, for verification, the individual / individuals listed below will be prepared to state my date of birth and/or the last four digits of my social security number. If the resyed information is unknown , the information requested may be denied.

I do not authoriza the Practice to release any or all information concerning my medical care to any individual except as set forth above.

NAME

RELATIONSHIP TO PATIENT

NAME

RELATIONSHIP TO PATIENT

PATIENT SIGNATURE *

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