Patient Intake Form

Disclosure and Consent
Right to access for friend,family member, caregiver or workplace.
Patient Name*

First NameLast Name
Birth Date*

MonthDayYear
Would you like to add a friend, family member or caregiver to allow them to communicate with the practice staff? ( if "YES" complete below, if "NO" skip and sign)*

YESNO
I _{patientName}_ direct my health care and medical services providers and payers to disclose and release my protected health information described below to:
Name of Authorized Person

First NameLast Name
Relationship to Patient
Health Information to be disclosed upon the request of the person named above: (check only 1 option)

Disclose my complete health record (including but not limited to diagnoses, lab tests,prognosis, treatment, and billing, for all conditions)Disclose ONLY Billing/Financial informationDisclose ONLY Medical information
Patient Signature*
Should be Empty:

Disclosure and Consent