Patient Information Release Form - Black River Family Health Practice

Patient Name: *

Date of Birth: *

Last 4 of Social Security #: *

I , give my permission to Black River Health Services, Inc to discuss the following information.

Discuss medical history, mental health history, financial information, and compliance of treatment with the following person(s):

1: 2: 3:

No one, only myself.

Patient Initial: *

I give my permission to the following person(s) to pick up prescriptions or other materials from Black River Health Services, Inc. for myself or legal dependents (children):

1: 2: 3:

No one, only myself.

Patient Initial: *

I give my permission to Black River Health Services, Inc. to:

Leave messages on my answering machine at home. *

Leave messages on my cell phone. *

Patient Initial: *

Right to Terminate or Revoke Authorization

You may revoke or terminate this authorization by submitting a written revocation to Black River Family Practice-Burgaw, Black River Health Center-Atkinson, or Maple Hill Medical Center-Maple Hill. You should contact your primary office to terminate this authorization.

Potential for Re-Disclosure

Protected Health Information that is disclosed under this authorization may be disclosed again by the person or organization to which it is sent. The privacy of this information may no be protected under the Federal Privacy Regulations.

Signature *

Date: *

Signature of Representative *

Date: *

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