Authorization to Discuss Health Information

AUTHORIZATION TO DISCUSS MEDICAL INFORMATION WITH DESIGNATED PARTIES
PATIENT'S NAME:
DATE OF BIRTH:

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Date
I VOLUNTARILY REQUEST AND AUTHORIZE DR. MARIA ABELLO-POBLETE AND THE STAFF OF POBLETE DERMATOLOGY, TO DISCUSS AND RELEASE HEALTHCARE INFORMATION OF THE PATIENT NAMED ABOVE TO THE FOLLOWING:

PLEASE DESIGNATE FAMILY AND FRIENDS WITH WHOM WE CAN SHARE YOUR MEDICAL INFORMATION WITH:
DESIGNATED PARTY
RELATION TO PATIENT
DESIGNATED PARTY
RELATION TO PATIENT
DESIGNATED PARTY
RELATION TO PATIENT
INITIAL: I understand that I can revoke this authorization at any time through a written request.RELATION TO PATIENT
Initial
INITIAL: I understand that my treatment cannot be contingent upon my signing of this authorization
Initial
PRINT PATIENT REPRESENTATIVE'S NAME
DATE

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SIGNATURE OF PATIENT OR PATIENT'S REPRESENTATIVE

Clear
DATE

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Should be Empty: