In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. I understand that the default answer is "NO". Without indicating "YES" in answer to the each
Any Member of my immediate family: (Spouse, Children, Children's Spouses)
Any Member of my extended family: (Parents, Grandchildren)
Name of Patient (Please Print):
Should be Empty:
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