• HIPAA Authorization, Private Information Share

    HIPAA Authorization, Private Information Share

  • Date of Birth
     - -
  • Date today
     - -
  • Date From
     - -
  • Date To
     - -
  • I acknowledge and permit Dr Caplan and HIPAA-compliant CED Clinic staff to communicate with my parents and others (noted below) about my medical cannabis care. This will take effect as of the dated this documentation is submitted to CED Clinic and until such time as I, the patient, request the document to be canceled (to be done in writing)
  • Please check all types of medical information that are ALLOWED to be disclosed
  • Other Information allowed to be disclosed
  • Date Signed
     - -

  • If you are beyond the age of legal consent (if you are under 18 or not an emancipated minor), click "next" for your guardian to counter-sign.

  • Parent or Legally Authorized Representative

    In case the subject is beyond the legal age of consent:

  • Date Signed
     - -
  • Should be Empty: