Professional Documents
Culture Documents
PATIENT INFORMATION
no
no
_____________________________________________ ______________________________
Patient
Date
_____________________
Date
_____________________________________________
_____________________
Relationship, if applicable
_____________________
Date
_____________________________________________
_____________________
Relationship, if applicable
___ Home
___ Cell
___ Home
___ Cell
Please indicate where we may leave detailed messaged regarding appointments, billing, test
results, medication, and other treatment issues:
Preferred Phone Number
I hereby authorize the doctor and/or hospital listed above to release my medical information
(appointments, lab/x-ray results, diagnoses, treatments, medications, surgeries, etc.) via postal
mail, telephone, fax, or email to the following family members:
Name: ___________________________ DOB: ____________ Relationship: ______________
Name: ___________________________ DOB: ____________ Relationship: ______________
Name: ___________________________ DOB: ____________ Relationship: ______________
Name: ___________________________ DOB: ____________ Relationship: ______________
Authentication:
_____________________________________________
_____________________
Date
_____________________________________________
_____________________
Relationship, if applicable
ACKNOWLEDGEMENT OF
RECEIPT OF NOTICE OF
PRIVACY PRACTICES
_____________________
Print Name
Date
_____________________________________________
_____________________
Signature
Date
AUTHORIZATION
FOR RELEASE OF
HEALTH INFORMATION
___ consultations
___ other
________________________________
Comments: __________________________________________________________________
__________________________________________________________________________
___________
From
___________
From
___________
From
___________
To
___________
To
___________
To
You may ask for and receive a copy of this authorization form.
This authorization will expire twelve months from the date you signed it. Additionally, you may
revoke authorization at any time by submitting a written request to this clinic or caretaker.
You have the right to inspect the information you are authorizing to be re-released.
Authorization:
________________________________________________________________________________
Printed Name of Patient or Authorized Representative
_________________________________________________
Signature of Patient or Authorized Representative
______________________________
Date
_________________________________________________
Signature of Witness
______________________________
Date
NOTICE OF
PRIVACY PRACTICES
This notice describes how medical information about you may be used or disclosed and how you
can get access to this information. Please review it carefully.
Understanding Your Medical
Record/Health Information