Consent For Release of Confidential Information: For Patients 18+ Years Old

Consent For Release of Confidential Information: For Patients 18+ Years Old
As an adult, your health information is private. With your consent, we can share certain aspects of your health information with identified individuals, such as your parents. Without your consent, we will not share any piece of your health information - including billing information or vaccine history - with others. You are not required to share your health information with anyone. This form must be filled out by the PATIENT, not by a parent or family member. Thank you!
Your Name

First NameMiddle NameLast NameSuffix
Your Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearBirthday
Your Email Address:
example@example.com
Please select one option below:
Items and Information to be Released Include (please select any or all of your choosing):
I consent to sharing the above information with the following people:
Person #1:

First NameMiddle NameLast NameSuffix
Relationship of Person #1 to Patient:
Person #1 Email:
example@example.com
Person #1 Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Person #2:

First NameMiddle NameLast NameSuffix
Relationship of Person #2 to Patient:
Person #2 Email:
example@example.com
Person #2 Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
I understand that my records are confidential and cannot be disclosed without my written authorization, except when otherwise permitted by law. I understand that I may revoke this consent at any time by giving written notice, except to the extent that action has been taken in reliance on it. If I wish to revoke this consent, I agree to contact Greater Cleveland Pediatrics for a new consent form.
Patient Signature:
Today’s Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: