Consent to Discuss - Cfcrexburg.com

Patient Name

Patient DOB

Age

NO INFORMATION

By checking here I agree to NO INFORMATION. I do not authorize the release of any information concerning my treatment. I understand that this includes Directory Information. I choose to be a “No Information” patient. If you have chosen to be a NO INFORMATION patient you will be required to type in N/A on first line.

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OR

STANDARD DISCLOSURE

By checking here I agree to the STANDARD DISCLOSURE. I understand that my health information is strictly confidential and cannot be released to anyone without my express permission. I authorize this clinic and medical staff members to discuss my medical history, diagnosis, treatment and prognosis with those listed below. I understand this may include information regarding testing, examination and treatment for HIV, AIDS related illness, mental health and drug, alcohol or chemical abuse. I understand this also includes billing questions, payment history and pending balances by insurance or individual. Those listed below may also pick up communication from my physician, such as prescriptions.

Names

Phone

Relationship to Patient

Name

Phone

Relationship to Patient

Name

Phone

Relationship to Patient

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I am

Representative Name

Representative Type

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Opt-In

By checking here, I acknowledge and affix my signature as the above-referenced patient or authorized patient representative. I consent to the release of information as specified. I understand that I may revoke my consent at any time, by requesting to fill and sign this form again at a later date.

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Walk-in Clinic Doctor Medical Clinic

Consent To Discuss Health Care Information