Patient Release of Information Form

First Name
Last Name
Date of Birth
 Today's Date

Dear Patient,
This form is required to release any of your medical information to your spouse, family, friends, physicians, attorneys, etc. Please complete at least one person or specify "None". Please note: if you state "None", we CANNOT release ANY information to anyone.

Relatives
Name: Date of Birth:
Name: Date of Birth:
Name: Date of Birth:
Name: Date of Birth:
Physicians
Name:
Name:
Name:
Name:
Other People
Name: Date of Birth:
Name: Date of Birth:
Name: Date of Birth:
Name: Date of Birth:
Communications

Please Indicate how you wish us to reach you:

1st Phone # Preference: OK to leave detailed message? Yes No
2nd Phone # Preference: OK to leave detailed message? Yes No
Acknowledgement

This release of information form will be in effect until notified of the contrary. If you want this form to expire on a particular date, indicate here.

Date of Expiration:

I hereby give permission for representatives of Digestive HealthCare Center, P.A. to release or discuss Protected Health Information (PHI) with the stated individuals on this form (listed above).