Authorization to Release and Disclose Patient Protected Health Information Logo
  • Patient Information Form

    Lamoille-500.34C
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  • Patients Preferred Contact Method

  • Responsible Party Information

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  • Patient Information

  • Patients Employer

  • Patients Emergency Contact Name

  • Primary Insurance Information

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  • Secondary Insurance Information

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  • Tertiary Insurance Information

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  • Patients Pharmacy Information

  • **As a patient of Lamoille Health Partners you can save money on home delivery brand name and generic medications by using Community Health Pharmacy. Ask the Front Desk for the Community Health Pharmacy Form if you are interested.

  • FOR PATIENTS UNDER THE AGE OF 18 PRIMARY CAREGIVER:

  • ***If you have Sole Legal Responsibility (Ability to make decisions regarding education, non-emergency medical and dental care, religion and travel) and only YOU can make these decisions for the Minor Please bring a copy of the Court Document stating this for our records.

  • Lamoille Health Partners has my permission to verbally disclose the following Medical and Billing information about me to:

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