Medical Release Of Information Form (Page 2 of 2) in pdf

Medical Release Of Information Form Page 2

Continuation of Release of Information for (Print Name): ________________________________________________

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:

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:

Signature: ________________________________________________ Date _______________________________

Medical Release Of Information Form Page 2