Gsa Form 13 Permission To Doctor - General Surgical Associates
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1GENERAL SURGICAL ASSOCIATES
I, _______________________ give permission to Dr.:__________________
(Name of Patient)
to share my medical information with the following people:
1. ________________________ Relation to patient ________________
2. ________________________ Relation to patient ________________
3. ________________________ Relation to patient ________________
This includes: scheduling / re-scheduling appointments for Clinical and
Surgery.
____________________________________
________________
Signature of Patient or Legal Representative
Date
____________________________________
_______________
Witness
Date
In addition, I also give permission for any test results to be released to the
person(s) listed above.
___________________________________
________________
Signature of Patient or Legal Representative
Date
____________________________________
_______________
Witness
Date
GSA Form 13 Rev 7-2013
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