Permission to Verbally Discuss Protected Health Information with Family and Friends

Permission to Verbally Discuss Protected Health Information with Family and Friends
Patient Legal Name:*

First NameMiddle InitialLast Name
Date of Birth:*

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Date
I full name give permission for Riverwood Healthcare Center to verbally discuss the information checked below with the family, friends, or others that I have identified below as being involved in my health care, care coordination, or payment of my health care. (Check all boxes that apply). This form does not authorize releasing copies of my records.
Scheduling/Appointment InformationMedical information, including my symptoms, diagnosis, medications, and treatment planBehavioral health information, including my symptoms, diagnosis, medications, and treatment planSubstance use disorderLab/test resultsBilling and payment informationOther
If you selected other, please describe: description
Riverwood Healthcare Center has my permission to discuss the above information with the following individuals:
Name:
Relationship to Individual:
Phone Number:
Name:
Relationship to Individual:
Phone Number:
Name:
Relationship to Individual:
Phone Number:
By signing below, I attest that I understand that I have the right to revoke my permission at any time except where Riverwood Healthcare Center has already made disclosures in reliance on this request. I understand that this permission remains in effect until the time I revoke it in writing.
Signature of Patient, or if Patient is unable to sign, Representative of the Patient

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Relationship to Patient (if patient is unable to sign)
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Permission to Verbally Discuss Protected Health Information with Family and Friends

Riverwood Healthcare Center has my permission to discuss the above information with the following individuals:

By signing below, I attest that I understand that I have the right to revoke my permission at any time except where Riverwood Healthcare Center has already made disclosures in reliance on this request. I understand that this permission remains in effect until the time I revoke it in writing.