Disclosure and Consent

Disclosure and Consent
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
I direct Raleigh Wellness Behavioral Health Staff so disclose and release my protected health information to the named individual below:
Name of Authorized Person*

First NameLast Name
Relationship to Patient:*
Phone of Authorized Person if known

Area CodePhone Number
Health Information to be disclosed upon the request of the person named above: (check only 1 option)

Disclose my complete health record (medical and billing)Disclose ONLY Billing/Financial informationDisclose ONLY Medical information (including but not limited to being part of my video appointments, diagnoses, lab tests, prognosis, treatment, and billing, for all conditions)
Patient Signature

Clear
Date

MonthDayYear
Date
Should be Empty: