LibertyMedhealthgroup.com - Family Correspondence

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

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

FAMILY CORRESPONDENCE