Permission to Disclose Healthcare Information

Permission to Disclose Healthcare Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I hereby authorize North Bethesda Primary Care to disclose at its discretion....
ANY aspect of my healthcare informationonly SOME of my healthcare information (PLEASE SPECIFY BELOW)
...to the following individual(s):
1.) Name*

First NameLast Name
Relationship*
2.) Name

First NameLast Name
Relationship
3.) Name

First NameLast Name
Relationship
Signature*

Clear
Date*

MonthDayYear
Date
Authorized Representative (if not the patient)

First NameLast Name
Relationship of Authorized Representative
Phone Number
Should be Empty: