Family First Physcians

Family First Physcians

Patient Release and Communication
Patient Name*
Date of Birth*

MonthDayYear
There are occasions when Family First Physicians may have to contact you to discuss Confidential Protected Health Information. Please let us know how you would like to get this information to you:

Okay to call my home/cell phone and leave a message on the answering machine regarding my Personal Health InformationOkay to call my home but DO NOT leave a messageOkay to email reminders if unable to reach by phone
If you would like us to contact you using a different phone number or email please fill out the part below.
Do not call my home number but call this number
Okay to email reminders to:
Who may recieve information regarding your Personal Health Information that you allow Family First Physicians to speak with? (optional)
Spouse
Children
Parents
Significant Other
Friend
I have received a copy of Notice of Privacy Practices from Family First Physicians, PLLC, and authorize the above list of persons' who many receive information regarding my Protected Health Information. I may revoke this any time by giving written notification to Family First Physicians, PLLC.
Patient/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: