www.currentderm.com - HIPAA Authorization for Family Members/Friends Form

HIPAA Authorization for Family Members/Friends
Patient Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
I hereby authorize the medical providers and personnel of Current Dermatology and Cosmetic Center (CDCC) to discuss and/or release my protected health information (PHI) to the following individuals:
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient
Name
Relationship to Patient
I understand that I have the right to revoke this authorization, in writing, at any time except where CDCC has already made disclosures in reliance upon this request. I understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law.
Signature*

Clear
Print Name*

First NameLast Name
Date*

MonthDayYear
Date
Relationship to patient (if other than self)
Should be Empty: