Consent for PHI Release to Family/Friends

Consent to Release Protected Health Information to Family/Friends

586 Oak Hill Road Williston, VT 05495 Telephone (802) 878-8131 Fax (802) 879-6853
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
I give permission for Thomas Chittenden Health Center to share my medical information with the family, friends or others that I have identified below as being involved in my health care, care coordination or payment of my health care.

I understand that I may revoke my permission at any time, and that this permission remains in effect until the time I revoke it, either in person or in writing.
Name and relationship of person(s) to receive information:
Family member/friend 1*
Name/relationship
Family member/friend 2
Name/relationship
Family member/friend 3
Name/relationship
The information may be shared in the following ways (check all that apply):*

Verbal discussions, either in person or by telephoneWritten or electronic information, including lab results, letters and progress notesPortal access through Authorized Representative
Signature*

Clear
Name of Signer*

First NameLast Name
Relationship to signer (if other than patient)
Date signed*

MonthDayYear
Date
Should be Empty:

Name and relationship of person(s) to receive information: