Consent to Disclose Information
DE M O
Care Provider: ____________________________________________________ Address: _________________________________________________________ Phone: _____________________ Fax: _____________________________ Email: ___________________________________________________________ Patient: __________________________________________________________ Date of birth: _____________________________________________________ Medicare number: _________________________________________________ Social security/insurance number: _____________________________________ Insurance provider: ________________________________________________ I, ____________________________authorize __________________________ to disclose information to the following person(s): ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________
A
1. 2. 3. 4. 5.
IS
This disclosure includes, but is not limited to: general health, diagnoses, treatment, medication, recommendations, and any other information that is important to my health status.
TH
IS
Please note the following specific requests: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ I understand that I may revoke this consent in writing at any time.
______________________________________ Patient signature
___________ Date
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