Individuals Involved In Care printable pdf download

Patient Name: ____________________________________________________ Birth Date: _______________________

Please Print

Please read the following and complete the information requested

You have the right to identify individuals other than your health care providers who are involved in your care

(family, friends, or others). We may verbally share your medical information to an individual you have identiﬁ ed

as involved in your medical care. We may also give information to someone who helps pay for your care.

EvergreenHealth will only share your health information with the individuals you designate, except as required or

permitted by law. You may add or change this list at any time.

Information related to Mental Health, Chemical Dependency, or HIV testing and/or therapy will only be shared with

you unless speciﬁ cally authorized below. (Sensitive Information)



I DO NOT authorize EvergreenHealth to verbally share information with anyone.

I authorize EvergreenHealth to verbally share medical information/billing information with the individuals listed

below:

Name

Relationship to Patient

Information to Share



All, including sensitive information



All, not including sensitive information



Speciﬁ c:___________________________



All, including sensitive information



All, not including sensitive information



Speciﬁ c:___________________________



All, including sensitive information



All, not including sensitive information



Speciﬁ c:___________________________

I agree I may be contacted for appointments or follow-up information about my care at the following numbers:



Primary contact # ____________________________

Ok to leave detailed message?

Yes



Secondary contact # _________________________

OK to leave detailed message?

Yes

These designations will remain in effect indeﬁ nitely or until otherwise revoked by me in writing.

Signature: _______________________________________________________ Date: __________________________

(if signed by a personal representative of the patient, please complete the following:)

Personal Representative’s Name: _____________________________________________________________________



Relationship to Patient:

Parent

Legal Guardian*

Holder of a Medical Power of Attorney*

* Please attach Legal Documentation if you are the Legal Guardian or Holder of Power of Attorney

Kirkland, WA 98034

APPLY PATIENT LABEL HERE

INDIVIDUALS INVOLVED IN CARE

FORM ID ADM 710

Original - Medical Record

Approved 02/14

Individuals Involved In Care

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