prestigeanklefoot.com - Permission to Verbally Discuss PHI

Permission to Verbally Discuss Protected Health Information with Family and Friends

Completion of this form is optional
Patient Name
Date of Birth

MonthDayYear
Date
Medical Record Number, if known
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Scheduling/Appointment informationMedical information, including my symptoms, diagnosis, medication(s) and treatment planLab/test resultsBilling and payment informationOther (describe):
Prestige Ankle & Foot Care, LLC has my permission to discuss the above information with the following family, friend(s) and other people. This information is directly relevant to their involvement in my health care (or payment for that care).
1. Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
2. Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient
I understand that in certain situations Prestige Ankle & Foot Care, LLC may speak to other individuals who are involved in my care or payment of that care, if permitted by law, that may not be identified on this form.

I understand that I have the right to revoke my permission at any time except where Prestige Ankle & Foot Care, LLC has already made disclosures in reliance upon this request. I understand that this permission remains in effect until the time I revoke it in writing.
Signature of Patient/Authorized Represent

Clear
Date

MonthDayYear
Date
If other than patient, state relationship and authority to
We have established a process that allows you to tell us who we may talk with about your health care. This includes appointment and scheduling information, lab and test results, treatment information and billing information.

How can I give others permission to get verbal information about me?

Complete the Permission to Verbally Discuss Protected Health Information form on the attached page to let us know whom we may speak to about your information. Check the appropriate boxes to indicate what information we may discuss, you may also send us a letter with this information.

Does this mean that you will not speak to anyone I haven't specifically names on the form?

No. If permitted by law, Prestige Ankle & Foot Care, LLC may speak to other individuals involved in your care (or payment for that care).

How is the information on the form used?

Any time your designated person calls or makes a request on your behalf, we will verify the individual has your permission to receive the information and then we will share the information.

What are some examples of when this might be useful?
- If an individual wants to share information with spouse or significant other
- If an elderly patient wants an adult child to help understand medical treatment instructions
- If an adult child is helping with billing questions
- If a friend is helping a patient with health issues
- If a college student wants information shared with a parent
- If an adult child calls to find out his/her parent's appointment time
What if I change my mind?
You can change or revoke (stop) this process at any time by writing to us at the address shown below.

What happens if I don't complete this form?
We will continue to protect your private health information as required by law.

Can the person I designate also get copies of my medical records?
No, they can only receive verbal information. To get copies of medical records, complete a separate Authorization form available by contacting the clinic at the phone number listed below.

Where do I send the completed form or any changes?
Please send or fax the completed form or any changes to the location listed below. Note: If you need to obtain copies of your health records, please contact the office using the address or phone number listed below.

Prestige Ankle & Foot Care, LLC
2483 Powder Springs Road SW; Suite C
Marietta, GA 30064
Phone: 678-370-0970
Fax: 678-370-0971
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Permission to Verbally Discuss Protected Health Information with Family and Friends