Permission to Disclose Protected Health Information (PHI) to Designated Individuals
Name
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First Name
Last Name
Patient Date of Birth:
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Consent to Release Information:
I hereby authorize Muskingum Valley Health Centers to discuss and disclose my protected health information to the following individuals. I am authorizing the use and disclosure of individually-identifiable health information relating to my care at MVHC. I understand that I may revoke this authorization at any time by contacting MVHC. I have listed the following designated individuals to be able to access my protected health information below.
1. Individuals name:
2. Individuals name:
3. Individuals name:
4. Individuals name:
Health Topics I do not want released or discussed: (Please mark all that apply.)
Psychiatric & Substance Abuse Information
Reproductive Health (Birth Control)
HIV/AIDS and Sexually Transmitted Diseases and/or Infections
By signing this agreement, I have authorized MVHC to disclose protected health information to the above listed individuals.
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Guarantor Printed Name:
Relationship:
Guarantor Signature
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