People Involved in Patients Care

Authorization - People Involved in Patients Care

Patient's Name

Date of Birth

Patient confidentiality is important to us and we will only share information with family and friends that you give us written permission to verbally share information with. If there are people involved in your care who should be able to receive verbal information about your health, your testing or your treatment, including appointment dates and times, please print the names below.

I know that information may be discussed with family members or others without this form, if allowed by federal and state laws.
I know that listing a person on this form does not allow them to obtain a copy of my medical records.
For a minor, parents are assumed to be designated except for those services which the minor has given consent under Michigan law.

Please list family member(s) and/or friends that you give us written permission to verbally share information with:

Name

Phone Number

Relationship

Name

Phone Number

Relationship

Name

Phone Number

Relationship

Name

Phone Number

Relationship

I do NOT wish to name anyone. If a patient is a minor, parents / legal guardians are assumed to be designated.

For minors:

Must have written permission for each visit if being brought in by someone other than parent/legal guardian or person(s) listed on this form.

I can update this form at any time by telling a Michigan ENT & Allergy Specialists staff member AND by filling out a new form. I can take away my permission to share my information at any time by putting that request in writing and giving that request to a Michigan ENT & Allergy Specialists staff member.

Signature indicates that I have read this form and I understand it and all of my questions have been answered.

Patient or Legal Guardian Signature

Date