Patient Authorization Form - Authorization To Release Information To Family Members printable pdf download

Patient Authorization Form - Authorization To Release Information To Family Members

PATIENT AUTHORIZATION FORM

Authorization to Release Information to Family Members

Many of our patients allow family members such as their spouse, significant other, parents or children to

call and request the result of tests, procedures and financial information. Under the requirements for H.I.P.A.A.

we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your

medical information, any diagnostic test results and/or financial information released to any family members

you must sign this form.

You have the right to revoke this consent, in writing, except where we have already made disclosures in

reliance on your prior consent.

I authorize Lincoln Eye & Laser Institute to release my records

and any information requested to the following individuals.

1. _________________________________ Relation to Patient:___________________

2. _________________________________ Relation to Patient:___________________

3. _________________________________ Relation to Patient:___________________

4. _________________________________ Relation to Patient:___________________

Authorization Regarding Messages

(please check all that apply)

____ I authorize you to leave a detailed message on my home or cell number regarding appointments

____ I authorize you to leave a detailed message on my home or cell number regarding medical

treatment, care, test results or financial information

____ I authorize you to leave a message with anyone who answers the phone

____ Messages may only be left with ______________________________________________

_________________________________________

__________________

Patient Name (PLEASE PRINT)

Date

_________________________________________

Patient Signature

S:\Front Office\Patient Forms\New Patient packets\Release of Information to Family Members.doc

Patient Authorization Form - Authorization To Release Information To Family Members