Authorization To Discuss Protected Health Information Form
ADVERTISEMENT
1Authorization to Discuss Protected
Health Information
Print patient’s legal name _____________________________________
(office use only: MR# _____________________ )
Previous names _____________________________________ Birth date ___/___/___
1. Phone Messages
My care team may leave information on my voicemail or answering machine at these numbers:
Home: _____________________ Cell: ______________________ Work: ______________________
Please share: ☐ Scheduling information
☐ Medical information
☐ Billing information
☐ Nothing
2. Person-to-Person Communication
To help with my care or billing, my care team may share information with these people:
___________________________________
___________________
______________________
First name, last name
Relationship to me
Best contact number
___________________________________
___________________
______________________
First name, last name
Relationship to me
Best contact number
___________________________________
___________________
______________________
First name, last name
Relationship to me
Best contact number
Please share: ☐ Scheduling information
☐ Medical information
☐ Billing information
☐ Nothing
I understand the following:
• This consent applies to University of Minnesota Health Clinics and Surgery Center, Inc., Fairview Health
Services, Range Regional Health Services and other clinics using their shared electronic. The clinics are
listed at
• My care team will release all details to the person or persons named above. This includes details about
treatment for mental health, chemical dependency, sickle cell anemia, genetic conditions and AIDS/HIV.
If I don’t want this information shared, I will write my initials here: ______________.
• This form does not have an end date. If I want to change the information on this form, I will fill out a new
form. If I want to add or remove people for person-to-person communication, I will fill out another form.
• Once my information is shared with the person or persons named above, it may no longer be protected
by privacy laws. Fairview cannot prevent these persons from sharing my information with a third party.
• If I do not sign this form, I will still be treated.
________
______________________________________________
________________________________________
Date/Time
Signature of patient or authorized person
Authorized person’s authority to sign (proof required)
Reason patient is unable to sign: ☐ Minor
☐ Other: ___________________________________
AUTHORIZATION TO DISCUSS PROTECTED HEALTH INFORMATION
521129 – Rev 12/17/15 Consent to Communicate
ORIGINAL to Chart
PHOTOCOPY as needed for Patient
Page 1 of 1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business