Emergency Contacts

(Disclosure Authorization)

Please correct the errors described below.

Please list the family members, close friends, or other people who we can notify regarding your care or with who we can discuss your protected health information. Protected health information consists of test results, diagnoses, billing information, insurance information and treatment options. This form will be effective until you provide further notice to us.

Emergency Contact:

(If patient is a minor, this must be a parent or guardian)

Others:

Add authorized person(s)

Patient Signature

I acknowledge my protected health information can be released to the people I have listed above. I have the right to revoke this form at any time in writing at the office listed above.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Please retain this form in the patient’s medical record.

Your information will be encrypted.

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