Greensboro Medical Associates- HIPAA Authorization Form
Please complete this authorization to allow Greensboro Medical Associates to disclose your health information as specified below.
Patient Full Name
*
I authorize Greenbrier Medical Associates to:
Leave messages on my answering machine or voice mail.
Report test results.
Discuss changes in my condition or my account with me.
Other - any specific directions are in the bottom of this form
Please List Full Names and Relations to Those Authorized For Above Statements
Driver License Number and State
*
Signature
*
Date
*
-
Month
-
Day
Year
Date
Name of Emergency Contact
Relationship
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Specific Directions Regarding Disclosure of Health Information
Submit Authorization
Submit Authorization
Should be Empty: