Medical Release Of Information Form printable pdf download

Medical Release Of Information Form

Release of Information

(This is not a release of medical records)

I, ________________________________________ , hereby give my consent to communicate with the following people:

Name:

Relationship:

Home Phone:

Cell Phone:

Check the box(s) that apply to what this person can do:

[ ] Emergency Contact

[ ] Pick up prescriptions or samples

[ ] Pick up referrals

[ ] Leave appointment reminder calls or call back request messages

[ ] By checking this box, you are authorizing us to release protected health information to this person i.e. test results

Please list any information that you would NOT like released to this person:

Name:

Relationship:

Home Phone:

Cell Phone:

Check the box(s) that apply to what this person can do:

[ ] Emergency Contact

[ ] Pick up prescriptions or samples

[ ] Pick up referrals

[ ] Leave appointment reminder calls or call back request messages

[ ] By checking this box, you are authorizing us to release protected health information to this person i.e. test results

Please list any information that you would NOT like released to this person:

For Patient Use:

[ ] OK to leave messages on:

Home phone:

Cell phone:

Work Voice Mail:

Other:

This form will be kept in your medical file for one (1) year or until you notify us of any changes you would like to make.

Consent for Treatment

hereby give my consent for treatment at TMC One Medical Group Wyatt

location. I agree to inform my Provider of my medical history, medications and substances that I take and any changes in

my health. I agree to have the Provider provide treatment or treatment options, and maintain my electronic medical

records. My permission will be obtained before any biopsies, injections, medications, treatment, or other foreign bodies

enter my body; I also understand that the Provider or Medical Assistant will explain all benefits and risks associated with

any suggested procedure as well as the risks and benefits of not receiving the suggested procedure.

Signature:

Date:

Medical Release Of Information Form