I hereby authorize and voluntarily give consent to the care and treatment provided to me by the Practice and its healthcare professionals (the "Providers"). I understand that such treatment may include, without limitation, routine medical, physician assistant and nursing care, as well as routine examinations, tests, and/or diagnostic procedures (collectively, "Medical Services"), including additional Medical Services at a later date. While routinely performed without incident, there may be certain risks associated with these Medical Services. My Provider will provide me with information about the Medical Services and answer all of my questions. I understand that it is not possible to enumerate each and every risk for every Medical Service. If I have further questions or concerns, I will ask my Provider to provide me with additional information.

 

I consent to and authorize the Practice and its Providers to perform Medical Services that they deem reasonably necessary or desirable in the exercise of their professional judgment, including those Medical Services that may be unforeseen or not known to be needed at the time my informed consent is obtained through this Form. My consent shall also extend to the treatment of all conditions which may arise during the course of such Medical Services, including those conditions which may be unknown or unforeseen at the time my consent is obtained through this Form.

I understand that the Practice and/or my Provider may ask me to sign additional Informed Consent documents relating to specific Medical Services that require separate informed consent. Any such additional Informed Consent document will include a description of the procedure, as well as the benefits, risks, and alternatives to the procedure.

 

MEDICAL INFORMATION: I understand that the Practice and its Providers, including my Provider, will rely primarily on my documented medical history, as well as other information provided by me in determining which Medical Services to perform and how to provide care and treatment to me in connection with those Medical Services. I agree to provide the Practice and its Provider with accurate and thorough information regarding my medical history and any conditions or events which may impact my Provider's clinical decision-making and to update this information when there are changes. I have informed my Provider of any known allergies to drugs or other substances, any past reactions to anesthetics, all current medications and supplements, my pregnancy/nursing status, and any illnesses and conditions I have.

I understand that I have the right to discontinue any Medical Service at any time.

I understand that the practice of medicine is not an exact science, and that no guarantees or assurances are made to me concerning the outcome and/or result of any Medical Service.

I understand that digital and other images may be recorded to document my care and I consent to such recordings. I understand that the Practice will retain the ownership rights to these digital and other images, but that I will be allowed access to view them or obtain copies. I understand that these images will be stored in a secure manner and kept for the time period required by law or outlined in the Practice's policy. Images that identify me will be released and/or used outside the Practice for teaching or publication purposes only upon written authorization from me or my legal representative.

I authorize the Practice to: (i) send me text message appointment reminders on my provided cell phone and email appointment reminders at my provided email address through the Practice's secure email system; (ii) communicate with me about other matters at my provided email address through the Practice's secure email system, and I understand that emails I send in return to the Practice may or may not be secure, depending on my system; (iii) communicate with me by phone and leave a message on my voicemail, including medical information about me (e.g., test results) and/or requesting me to call back; and (iv) communicate with me via email through the Practice's patient portal, and I understand that patient portal emails are a secure means for communicating information about me from the Practice to me and from me to the Practice.

 

I understand and agree that any information I communicate to the Practice through text or regular email may not be secure, and to the extent that I elect to use such communication methods, I acknowledge and accept the risk of doing so.

 

I understand that in the event of an emergency, I should call 911 or go to my closest emergency room or urgent care center, as appropriate in light of the circumstances.

Telehealth involves the use of technology assisted media or electronic communications to enable Practice Providers to provide services to me when the Provider and I are at different locations.

By my signature below, I understand and agree to the following:

1. There are potential risks associated with the use of telehealth and I agree to accept them. These risks include, but are not limited to:

• In rare cases, information transmitted may not be sufficient (e.g., poor resolution of images) to allow for appropriate medical decision making by the Provider;
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In rare instances, security protocols could fail, causing a breach of privacy of personal medical information; and
• Disruption due to technology failures.

2. Reasonable efforts will be made to use electronic systems that will incorporate network and software security protocols to protect my privacy and the confidentiality of my information, and that reasonable efforts will be made to include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

3. I must be physically present in the state of Massachusetts during each telehealth session.

4. I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment. I also understand that my Provider may decide to discontinue use of telehealth if it is felt that the connections are not adequate for the situation, or for any other reason.

5. I will conduct telehealth sessions in a private place so other people cannot overhear anything said during my session.

6. I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.

7. Telehealth should not be used in emergency situations, and if I am experiencing an emergency, I should call 911 or go to my closest emergency room or urgent care center, as appropriate for the circumstances.

8. I hereby consent to and permit my Providers to use telehealth in my medical care.

By my signature below, I hereby certify that I have read this Informed Consent Form in its entirety, that any questions I had about its contents have been answered to my satisfaction, and that I fully understand its contents. This Informed Consent Form will be valid for all services provided by the Practice and its Providers. If I wish to revise my consent, I may do so by completing a new Informed Consent Form. If I wish to withdraw my consent, I must do so in writing and submit it to the Practice.

It is important that you are familiar with your own coverage and insurance terms. Understanding what your insurance plan covers—including co-payments, deductibles, co-insurance, and lab contracts—is your responsibility.

• If your insurance changes at any time, please notify our office promptly to update your information.
• It is your responsibility to contact your new insurance company to confirm that we are in-network with your updated plan.
• All co-payments, co-insurance, and deductibles are due at the time of your visit.

We encourage you to familiarize yourself with your financial responsibilities to ensure a smooth experience.

The Practice participates in many insurance plans. If we have notified you that we contract with your insurance carrier, you are an in-network patient. The benefits paid by insurance companies for dermatologic services vary by carrier and by plan, and insurance companies may not pay for all medical services and procedures, even those that might be helpful to you. Please contact your insurance carrier to determine insurance coverage. If you have any questions about your insurance coverage, we will make reasonable efforts to assist you in verifying your insurance benefits and preauthorization requirements, as a courtesy to you. Please bring your insurance card with you to every visit so that we can verify your current insurance. Your insurance plan may require you to obtain prior authorization and/or a referral from your primary care physician. It is important to understand that any prior authorization and/or pre-approval granted by your insurance company is not a guarantee of payment by your insurance company. If insurance coverage is available, we collect applicable co-payments, co-insurance, and deductibles at the time of service. We are required by law to submit every claim to an insurance company accurately, reporting the exact services performed and the exact reason for performing them. We cannot and will not change information just so the claim can be paid by an insurance company. If services were denied by your insurance, you will be notified ahead of time electronically by e-mail and/or text message and will have 4 weeks after such notice to pay the full balance due. Cosmetic procedures are not covered by insurance plans. You will be responsible for all fees related to cosmetic services and procedures at the time of your visit. You are ultimately responsible for the full payment of your account for all services provided by the Practice. If your insurance denies payment, you agree to be personally and fully responsible for full payment.

If we have notified you that we do not contract with your insurance carrier, you are an out-of-network patient. We will provide you an estimate of the amount due and as an out-of-network patient, you will be responsible for the direct payment of that amount to the Practice. You are welcome to seek reimbursement from your insurance carrier, and any such reimbursement will be paid directly to you. We are unable to submit a claim to your insurance company for your medical visits and services. Additionally, you will be responsible for all fees related to cosmetic services and procedures at the time of your visit. You are ultimately responsible for the full payment of your account for all services provided by the Practice. You agree to be personally and fully responsible for full payment.

All such patients are billed directly by the Practice. You will be responsible for all fees related to cosmetic services and procedures at the time of your visit. You are ultimately responsible for the full payment of your account for all services provided by the Practice. You agree to be personally and fully responsible for full payment.

If your insurance requires a referral from your Primary Care Physician (PCP) for specialty services, it is important to ensure the referral is in place before your visit. Without a referral, you will be responsible for covering the cost of all services provided.

As a small practice, we rely on timely payments and appointment attendance to continue serving our community. This Policy helps us protect appointment availability and keep our operations running smoothly. We understand that schedules can change unexpectedly, and we're here to help you reschedule when needed. However, to ensure we can accommodate all our patients effectively, if you are unable to keep your appointment, we require advance notice:

• Medical, surgical, Mohs, and cosmetic appointments: At least 24 business hours in advance.
• Business hours: Monday through Friday, 8:00 AM to 5:00 PM.

Arriving more than 10 minutes late for your appointment will be considered a late cancellation. If you fail to cancel/reschedule within the allotted time, the following fees will apply:

• $50 for a medical appointment.
• $100 for a cosmetic, surgical, or Mohs appointment.

Example: For a Monday 8:00am medical appointment, cancellation must be made by the previous Friday at 8:00 am. Your credit card on file will be charged in the amount noted above within 48 hours of the missed appointment/late cancellation.

Delinquent payments, multiple late cancellations, and/or multiple no-show appointments may result in dismissal from the Practice. You will not be able to be seen as a patient if you have a balance over 60 days due or if your account goes to collections until your balance is paid in full.

Cosmetic services are not covered by insurance. Payment for these services is due at the time they are rendered. Please note that a deposit will be required for certain non-covered cosmetic procedures. Some medical services may also not be covered by insurance (e.g., treatment of benign lesions for cosmetic reasons). It is your responsibility to understand whether or not any services will be covered. Payment is due at the time of service for non-covered procedures.

There is no guarantee that a product or service will meet all your expectations. There are no refunds for products or services rendered. Exchanges or replacements for defective products may be considered on a case-by-case basis. In the event of an overpayment after insurance adjustments have been made for a service you received, you will receive a refund of the overpayment by check or original method of payment (if credit card or debit card were used).

An adult or guardian must accompany a patient under the age of 18 and is financially responsible for full payment for services rendered to the minor.

If you believe there is an error in the charges made to your account, please contact our office within 30 days of the charge. We will use our best efforts to investigate and resolve any billing concems promptly. You can reach us at 617-540-5570.

By my signature below: (i) I acknowledge that I have read and fully understand the Practice's Financial Policy, (ii) I acknowledge that I have had an opportunity to ask questions and all of my questions have been answered to my satisfaction, (iii) I understand that I am, and I agree to be, financially responsible for all costs associated with my treatment and procedures, (iv) to the extent that I am an in-network patient and my insurance carrier covers any of the services provided to me, I hereby irrevocably authorize my insurance company, Medicare, or any other third-party payment programs to pay benefits for services directly to and authorize assignment of benefits to the Practice, and (v) I agree to abide by and be bound by this Financial Policy and Patient Agreement.

Requirements:
All patients are required to keep an ACTIVE credit card on file with Greater Boston Dermatology. The credit card must be in the name of the patient or the patient's authorized representative.

Use of the Credit Card:
The credit card on file will only be used in accordance with the following:

• For services that are not covered by insurance, we will charge your card on file in the amount of the charge for the service provided by the Practice, unless you provide a different form of payment at the time due.
• For services that are covered by insurance, once an insurance claim has been processed by your insurance plan, your plan will send you and the Practice an explanation of benefits (EOB) which includes the amount of your responsibility for services. You will receive an electronic reminder through Patient Gateway to pay your Practice bill. If payment is not received by the Practice by the date indicated on your bill, we will charge your card on file the amount indicated as your responsibility. We will only charge the amount that we are instructed to by your insurance plan in the EOB that they send to us after your date of service.
• Late cancellation/no-show fees, in accordance with the Financial Policy and Patient Agreement.
• Copays, deductibles and co-insurance, unless you provide another form of payment at the time due.

Changes to Credit Card Information:
Patients are responsible for keeping their credit card information up to date. If the credit card expires or is lost, the patient must notify Greater Boston Dermatology immediately.

Greater Boston Dermatology takes the security of patient information very seriously.

• Your credit card will be entered into our payment processing system directly and stored securely.
• Your card on file will be encrypted. Your full credit card number will never be displayed to the Practice.

We value your privacy and will keep your payment information stored securely in accordance with HIPAA guidelines and will not be shared with any third parties.

If the credit card on file is declined, we will contact you to provide an updated form of payment. Outstanding balances must be settled within 10 business days to avoid interruptions to your care.

At Greater Boston Dermatology (the "Practice"), your comfort, dignity, and safety are our highest priorities. You will, to the best of our ability, be offered a trained medical chaperone during any examination or procedure, especially those involving sensitive or intimate areas (such as full-body skin checks or exams of the breasts, groin, or genital area). You may also request a chaperone of a specific sex or gender identity, and we will accommodate when reasonably possible. Chaperones are medical professionals (like nurses or medical assistants) and are there to support both you and the clinician. They will always maintain your privacy and confidentiality. If you or your provider are not comfortable proceeding without a chaperone, a follow-up plan can be arranged. You will always be informed if a chaperone is present.

To ensure a safe and professional environment for all patients and staff, we ask that you follow the guidelines below during your care with us.

1. Respect for Staff and Other Patients:

• Treat all staff, clinicians, and fellow patients with courtesy and respect at all times.
• Abusive, threatening, or discriminatory language or behavior will not be tolerated.
• Harassing phone calls, repeated inappropriate messages, or verbal abuse via voicemail, email, or patient portals are strictly prohibited and may result in termination of care.
• Follow all instructions provided by staff and clinicians regarding office policy.

2. Appointment Conduct:

• Arrive on time for appointments and notify the office as soon as possible if you need to cancel or reschedule. Please refer to the Financial Policy and Patient Agreement for fees charged for late cancellation and no-show appointments.
• Excessive missed appointments or late cancellations may affect your ability to book future visits and may result in termination from the Practice.

3. Appropriate Behavior During Exams

• Follow staff guidance during skin exams and procedures. Disrobing will be conducted in a respectful and private manner.
• Sexual or inappropriate behavior, comments, or advances toward staff or other patients will result in immediate action and possible dismissal from the Practice.

4. Confidentiality and Privacy

• Please respect the confidentiality of other patients in the Practice.
• Respect the privacy and personal space of other patients in the waiting area and clinical areas.

Violations of this Code of Conduct may result in warnings, removal from the premises, discharge from the Practice, and/or involvement of law enforcement, as determined by the Practice in its sole discretion.

At Greater Boston Dermatology, we are committed to providing equitable access and accommodations for patientswith disabilities in accordance with the Americans with Disabilities Act (ADA). If you require specificaccommodations, please inform our staff prior to your appointment so we can assist you.

Greater Boston Dermatology reserves the right to update or modify this Chaperone Policy, Patient Code of Conduct, and ADA Statement at any time.

By my signature below:

(i) I acknowledge that I have read and fully understandmodify this Chaperone Policy, Patient Code ofConduct, and ADA Statement at any tim the Practice’s ChaperonePolicy, Patient Code of Conduct, and ADA Statement,

(ii) I acknowledge that I have had an opportunity toask questions and all of my questions have been answered to my satisfaction,

(iii) I agree to abide by and bebound by this Chaperone Policy, Patient Code of Conduct, and ADA Statement

Only if applicable:

If the patient is an unemancipated minor or otherwise incapacitated (physically or mentally), obtain the following signature:

• We collect PHI, including but not limited to, your name, contact information, medical history, and treatment records, to provide you with quality dermatological care. With your consent, we may disclose information about you to other health care providers who are involved in your care and treatment.

Treatment:

• We may use your PHI to provide treatment, such as conducting tests and writing prescriptions. With your consent, we may share information with other providers involved in your care.

Payment:

• We may use, and with your consent, disclose your PHI to bill for services, verify insurance coverage, collect payments from insurers or third parties, and bill you directly.

 Health Care Operations:

• We may use, and with your consent, disclose your PHI for operational purposes, such as evaluating care quality and planning, obtaining legal services, etc.
• Messaging and Appointment Reminders.
• We may use and disclose your PHI to remind you of and confirm upcoming appointments.
• We may use and disclose your PHI to contact you about weather-related changes and changes in office hours.
• We may use and disclose PHI when responding to messages you send us or to contact you about your care.

 Treatment Options:

• We may use and disclose your PHI to inform you about potential treatment options or alternatives.

Health Related Benefits and Services:

• We may use, and with your consent, disclose your PHI for operational purposes, such as evaluating care quality and planning, obtaining legal services, etc.

Bussiness Associates: 

• We may disclose your PHI to business associates, such as contractors or billing companies, to assist with payment or health care operations.
• If we disclose your PHI to a business associate, we will have a written contract that requires the business associate to protect the privacy of your PHI in accordance with applicable law.

Release of Information to Family/Friends or Individuals Involved in Your Care or Payment for Your Care:

• Unless you tell us otherwise, we may share your PHI with a family member, close friend, or anyone else you identify if they are directly involved in your care or payment for your care.
• If you are unable to agree or object, we may share the information if we believe it is in your best interest, using our professional judgment. In this case, we would disclose only PHI that we believe is directly relevant to the person’s involvement with your health care or with payment related to your health care.
• We also may disclose your PHI in order to notify (or assist in notifying) such persons of your location, general condition or death.
• You have the right to name a personal representative who may act on your behalf to control the privacy of your PHI. Parents and guardians will generally have the right to control the privacy of PHI about minors unless the minors are permitted by law to act on their own behalf.

 

• Except as noted below, we do not share your PHI with third parties without your authorization.
• We may disclose PHI for public health reporting – for example: (1) report child abuse or neglect, elder abuse, disabled persons abuse, rape and sexual assault; (2) report medical information for the purpose of preventing or controlling disease, injury or disability; (3) report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) report information to your insurer and/or the Massachusetts Industrial Accident Board (and any party involved in the Workers’ Compensation matter) as required under laws addressing work-related illnesses and injuries or workplace medical surveillance; (5) if we know or have reason to believe that you are infected with a venereal disease, to alert your fiancée, if you are engaged, or your spouse, if you are married; and (6) file a death certificate.
• We may disclose your PHI in the course of legal or administrative proceedings in response to a legal order or other lawful process.
• We may disclose your PHI to prevent or lessen a serious and imminent threat to your health, safety, or the safety of others, but only to someone who is reasonably able to lessen or prevent the threat, including the target of the threat.
• PHI may be shared with health oversight agencies as required by law. Health oversight activities include audits, investigations, inspections, licensure or disciplinary actions, and civil, criminal or administrative proceedings or actions. We also are required to disclose your PHI to the Secretary of Health and Human Services, upon request, to determine our compliance with HIPAA.
• We may disclose your health information to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena accompanied by a court order.
• We may release PHI to a coroner, medical examiner, or funeral director as necessary for their duties, as authorized by law.
• We may disclose PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities as required by law.
• PHI may also be released to protect the President, other authorized persons or foreign heads of state or to conduct special investigations as required by law.
• We may disclose your PHI for research purposes with your written authorization, unless a special process determines that a waiver of authorization poses minimal risk to your privacy.
• If you are an organ donor, we may disclose your PHI to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.
• We may use and disclose your PHI when required to do so by federal, state or local law.

•  Right to Paper Copy of this Notice:You have a right to receive a paper copy of this Notice, even if you have agreed to receive this Notice electronically.
• Paper copies are available upon request. You can access an electronic version of this Notice at www.greaterbostondermatology.com

Right to Inspect and Copy PHI:

• You have the right to inspect and copy your PHI that we hold in a designated record set. This usually includes medical records (excluding psychotherapy notes) and billing records. 
• You have the right to request and receive your PHI in an electronic format when available.
• For paper copies, we may charge a reasonable fee for labor or related supplies.
• For portable electronic copies, we may charge a reasonable fee for labor or related supplies.
• We generally have up to 30 days to make your PHI available to you. If more time is needed to respond, we will notify you within the specified timeframe, explaining the delay and providing an updated response time.
• If you wish to access your records, please submit your request in writing.

Right to Amend:

• If you feel that your PHI we have is incorrect or incomplete, you may make a written request to amend the information. We will not make changes to medical information created by another health care provider or changes that would make your medical record inaccurate or incomplete.

Right to an Accounting of Disclosure:

• You can request a written list of certain disclosures of your PHI – that is, a list of how and to whom disclosures have been made. This request must be submitted in writing.

Right to Confidential Communications:

• You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work.
• We will accommodate reasonable written requests.

Right to Request Restrictions:

• You have the right to request restrictions on the use or disclosure of your PHI for treatment, payment, or healthcare operations.
• You may also ask us to limit the disclosure of your PHI to specific individuals, such as family members or friends involved in your care or payment for your care.
• We will consider your request; however, we are not required to agree to the restriction, except as noted below.
• If you pay in full, out-of-pocket for a service or item and request that we not share related PHI with your health plan, we will honor this request unless otherwise required by law.
• You can revoke a restriction at any time, and in some cases, we may also revoke it with prior notification or your consent.
• If we agree to a restriction, we will follow it unless the information is needed for emergency treatment.
• Restriction requests must be submitted in writing and include: the information to be restricted, whether the restriction applies to use, disclosure, or both, and the individuals to whom it applies.
• We are not required to agree to all requests, and some restrictions may not be allowed by law.

Right to Revoke Your Authorization:

• You have the right to revoke your authorization (or consent) to our use/disclosure of your PHI, as long as you make your request in writing to us.
• You can revoke your authorization (or consent) for future disclosures, but not for any disclosures made prior to when you first gave your notice of revocation.

• Authorization is required to release highly sensitive PHI. This includes but is not limited to your HIV/AIDS status; behavioral health documentation; sexually transmitted diseases; psychotherapy notes; substance use disorder information protected by federal law; and certain genetic information.
• Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with your written authorization.

• Your PHI will not be used for marketing or sold without your explicit written authorization. You have the right to revoke this authorization at any time.

• We employ industry-standard security measures to protect your PHI from unauthorized access, disclosure, alteration, or destruction.
• Incidental disclosures of your PHI may occur despite our efforts to safeguard privacy, such as other patients hearing your name during check-in.

• Your PHI is retained for the duration required by law and securely disposed of in compliance with applicable regulations when no longer needed.

• In the event of a breach of your unsecured PHI, we will notify you promptly and take appropriate steps to mitigate potential harm.

• All members of our staff are trained on HIPAA regulations and are required to adhere to this Notice. Any violations are addressed promptly and appropriately.

You have the right to revoke your consent or authorization for certain uses or disclosures of your PHI by submitting a written request.

• We are required by law to: make sure the privacy of your PHI is maintained, provide you with this Notice of our legal duties and privacy practices, and abide by the terms of the Notice that is currently in effect.
• We reserve the right to change this Notice and make the new Notice apply to PHI we already have as well as any information we receive in the future.
• We will post a copy of our current Notice at our office in a clear and prominent location. The Notice will contain the effective date on the first page.
• You may request a copy of the Notice at any time.

• If you have any questions or concerns regarding your privacy rights or the information in this Notice, please contact your physician Dr. Rebecca Jacobson at the address below.
• If you are making any written requests, please address the request to us at the following address: Greater Boston Dermatology PC,85 Lincoln Street, Suite 510, Framingham, MA 01702.
• If you would like to submit a comment or complaint about our privacy practices, you can do so by contacting your physician Dr. Rebecca Jacobson at the address above. You also may contact the Secretary of the Department of Health and Human Services.
• You will not be penalized or otherwise retaliated against for filing a complaint.

Office for Civil Rights

Department of Health and Human Services

200 Independence Ave., SW

Rm. 509F, HHH Building

Washington, D.C.  20201

Email: ocrprivacy.@hhs.gov

Website: https://www.hhs.gov/hipaa/filing-a-complaint/index.html

By my signature below, I agree to receive in electronic form and hereby acknowledge that I have received a copy of the practice's Notice of Privacy Practices and have therefore been advised of how information about me may be used and disclosed by the Practice and how I may obtain access to and control this information.

By my signature below, I herby authorize the Practice to disclose my information so that the Practice may treat me, seek payment from third parties for such treatment, and generally carry on the health care operations of the Practice (e.g., quality assurance). I also authorize the Pracatice to disclose my information to insurers and providers outside of the Practice when necessary for purposes of my treatment, and for their health care operations.

I understand that my medical records currently contain or my contain in the future the following types of highly confidential information, and by my signature below, I specifically consent to the disclosure of the following types of highly confidential information so that the Practice may treat me, seek payment from third parties for such treatment, and generally carry on the healthcare operations of the Practice (e.g, quality assurance).

I also authorize the Practice to disclose such high confidential information to insurers and providers outside of the Practice when necessary for purposes of my treatment, payment for that treatment, and for their health care operations.

 

By my signature below, I also authorize the Practice to disclose my general information (and my highly confidential information if necessary) to the following individuals (e.g. spouse/Partner, Children, other family and friends).

*If patient is a minor please list anyone including parents/guardians that my call or take patient to appointments

Only if applicable:

If the patient is an unemancipated minor or otherwise incapacitated (physically or mentally), the following must be completed by the patient's legally authorized Personal Representative: