Authorization to communicate with third parties

Release of Information

You have the right to request that we restrict how protected health Information about you is used or disclosed. Most patients have family members or friends that occasionally become involved in thier care. (For example, your spouse calls to confirm your appointment time; OR your adult child calls with questions about your medication.) Please list any restrictions to the information we can communicate about you with those you have lists below. (Example: Appointments only, financial matters only; Medications Only, etc. If there are no restrictions, please list “NONE” beside their name). Please list below any persons you will allow us to talk with about you. (If you prefer we do not speak with anyone, please write “NO ONE” across this section).

PLEASE INCLUDE ANY EMERGENCY CONTACTS, PARENTS, OR OTHER RELATIVES THAT MAY BE INVOLVED IN YOUR TRATMENT. OUR PROVIDERS WILL BE UNABLE TO SHARE ANY INFORMATION UNLESS LISTED BELOW.