LibertyMedhealthgroup.com - Family Correspondence

FAMILY CORRESPONDENCE
Re: Permission To Discuss & Release Health Information
Patient Name:
DOB:

MonthDayYear
Date
Please list below the names of the individuals you give us permission to discuss and release your medical/health information with:
By submitting this form, I hereby grant the above provider permission to discuss and release my medical/health information with any of the individuals listed above. All prior designations are hereby revoked.
Patient Signature:

Clear
Date:

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Date
Should be Empty:

FAMILY CORRESPONDENCE