Permission to Share Information

If you request Integrated Gastroenterology Consultants to share your medical information with another person or organization, please fill out all sections below. This will inform our facility as to whom you would allow us to share with. If you leave any sections blank, we will not be able to share information with the person(s) or organization you listed on this form.

I, your name give permission for Integrated Gastroenterology Consultants to share ALL of my information with, blank

Reason for Sharing Information

Please describe the reason(s) for sharing this information. If you do not wish to list reason(s), you may simply write: “At my request,” if you are initiating the request.

Please list your reason(s) above

This permission to share information is valid until blanks If you do not list a date or event, this permission will last one year from the dates signed.

By signing below, I acknowledge that I understand the following:

I can change my mind and cancel this permission at any time. To do so, I need to write a letter to Integrated Gastroenterology Consultants of Greater Lowell, and send or bring it to the place where I am late to change my mind and cancel permission.
I do not have to give permission to share my information with the person(s) or organization listed.
If I choose not to give this permission or if I cancel my permission, I will still be able to receive any treatment or benefits that I am entitled to, as long as this information is not needed to determine if I am eligible for services or to pay for services that I receive.

Signature

Print Patient's Name

Date

DOB