Authorization for Verbal Communication Between Providers

Authorization for Verbal Communication Between Providers

ALL SECTIONS BELOW MUST BE COMPLETED FOR PROCESSING
Patient Name*

First NameLast Name
Maiden or Former Name:
Relationship to Patient:
Date of Birth:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:*
Please enter a valid phone number.
PURPOSE OF THIS RELEASE:
Communication between:*
Name of AFP Provider
&*
Name of Outside/Other Contact
Phone Number*
Number of Outside/Other Contact
Medical information to be released:

All information deemed necessaryBeginning of treatmentSpecific dates
All information deemed necessary
Beginning of treatment MM/YYYY
End of treatment MM/YYYY
Specific dates
Release of sensitive, protected information related to testing, diagnosis and/or treatment for HIV/AIDs, sexually transmitted diseases, drug/alcohol use/treatment and/or mental health/psychiatry is authorized only through express consent

INDICATE THE AREAS YOU AUTHORIZE by INITIALING EACH ONE BELOW. AUTHORIZATION IS NOT VALID UNLESS INITIALED:
HIV/AIDs
Initial
Sexually Transmitted Disease
Initial
Mental Health/Psychiatry
Initial
Drugs/Alcohol
Initial
This authorization expires on (please fill in date) or if unspecified, discharge from treatment/service.
I understand that I may revoke this authorization at any time by making a written request to Atkinson Family Practice. I understand that actions taken in reliance on this authorization prior to revocations may not be reversible. I understand that Atkinson Family Practice may not condition treatment, payment, enrollment or eligibility for benefits on my signing this authorization. State law prohibits re-disclosure without written authorization.

I acknowledge that I have signed this authorization willingly:
Signature of Patient/Authorized Representative*

Clear
Print Name of Patient/Authorized Representative*
Date*
Should be Empty: