Authorization to Release Medical Information
to Individuals / Family Members
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. *
PATIENT SIGNATURE *
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