Patient Information Form (Page 2 of 3) in pdf

AUTHORIZATION for USE and/or DISCLOSURE of

PROTECTED HEALTH INFORMATION

I authorize the use and/or disclosure of my protected health information. I understand that this authorization is

voluntary.

I understand that, if the persons or organizations I authorize below are not health care providers, they may further

disclose the protected health information and it may no longer be protected by federal health information privacy

laws.

Patient Information (please print):

Name: ______________________________________________________________________________________

Date of Birth: ______________________________

Protected Health Information to Be Used and/or Disclosed:

□

Yes

May we discuss medical information regarding your care, test results,

appointments or billing information with someone other than yourself? Please list any

individuals you wish to have this permission.

NAME

RELATIONSHIP

□

Yes

May we leave a message regarding your medical care on your voicemail? If

yes, please provide the phone number:__________________________________________

□

Yes

May we send you appointment reminders via Text Message? If yes please

provide the phone number:___________________________________________________

(Please note data charges may apply per your cell phone carrier)

Expiration: This authorization will remain in place until a notice of change is provided in writing

I acknowledge that I have been made aware of Wilmington Health’s Notice of Privacy Practices. I have had full opportunity

to read and consider the contents of the Wilmington Health Notice of Privacy Practices.

Signature: ______________________________________Date: _________________________

If this authorization is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative’s Name: __________________________________________________________________

Relationship to Patient: _________________________________________________________________________

HIPPA Form 1 (revised 2/12/2016)

Patient Information Form Page 2