Permission for Verbal Communication

Permission For Verbal Communication

Clarinda Regional Health Center
Name of Patient*

First NameLast Name
DOB (Birth Date)*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
I permit CMHC Clinic, their physicians, nurses, and other personnel (“Health Care Providers”) to discuss health information, in person or by telephone, with the following family members or friends involved in my medical care: (List family members/friends and state the person’s relationship to the patient).
This authorization is limited to discussions regarding the following medical condition(s):
Blank

(If no limitations are listed, discussions will be permitted regarding any medical condition for which the patient has received care.)
Person 1*

First NameLast Name
Phone Number *
Please enter a valid phone number.
Relationship*
Would you like to add a second person with which health information can be discussed?*

YesNo
Person 2*

First NameLast Name
Phone Number *
Please enter a valid phone number.
Relationship*
Release of information under this document is limited to verbal discussions with my Health Care Providers. This document does not permit release of any written health information to the individuals named above.
This authorization is limited to the following time frame from blanks to (date)

(If no dates are indicated, this form will remain in effect for an unlimited amount of time.)
If, at any time, I do not want verbal discussions to be permitted between my Health Care Providers and any of the individuals named above, I must notify my Health Care Provider by contacting the CMHC Health Information Dept.
Patient Signature*

Clear
Date of Signature*

MonthDayYear
Date
Are you a representative signing on behalf of the patient?*

YesNo, I am the patient.
If this Release is signed by a representative on behalf of the patient, complete the following:
Representative's Name*

First NameLast Name
Relationship to Patient*
Should be Empty:

Permission For Verbal Communication