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)
Other
Name of Patient (Please Print):
Signature
Clear
Preview PDF
Submit
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm