Consent for Release of Confidential Information
Authorization for Start Bright to Use or Disclose Personal Health Information (PHI)
Patient's Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I hereby authorize the use and disclosure of protected health information (PHI) regarding the individual named above. I am:
*
the individual named above
the parent or guardian of the individual named above
I, the undersigned, authorize and request Start Bright permission to: (check all that apply)
*
Release confidential records
Obtain confidential records
Verbally communicate with
Other (specify below)
If you selected "Other," please specify:
This consent is valid through:
*
Specific end date (specify below)
End of therapy services
If you selected "Specific end date," please enter the date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
List the names of people or organizations included on this consent. Click "Add Row" to add more entries.
*
Name of Signee
*
First Name
Last Name
Signature
*
Date of Signature
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Consent
Submit Consent
Should be Empty: