Authorization For Release Of Information

WELCOME TO THE COMMUNITY FOOT CLINIC

Patient Name:

Acct #:

AUTHORIZATION FOR RELEASE OF INFORMATION

I hereby authorize Dr. John Enger DPM to use or disclose my Personal Health Information (PHI) as described below. I understand that, if the organization authorized to receive my PHI is not a health plan or health care provider, the released PHI may use and disclose this protected health information. You have a legal right to review our Notice of Privacy Practice. It is available upon request.

Patient authorizes communication with family/friends regarding your care and test results.

Name:

Phone #:

Relation:

Add new row

Patient authorizes communication with family / friends regarding your account and billing.

Name:

Phone #:

Relation:

Patient authorizes communication with a primary care physician or other physician (first and last name):

1. M.D.

2. M.D.

Best way to contact you regarding messages, responses, appointment reminders etc.

Home Phone

Work Phone

Cell Phone

E-mail Text

May we leave a message on home voicemail?

Yes No N/A

May we leave a message with whomever answers the home phone?

Yes No N/A

May we call your work and leave a message with the person who answers the phone?

Yes No N/A

May we leave a message on work voicemail?

Yes No N/A

May we contact you via Email? Email Address:

You have the right to revoke this consent in writing, except to the extent we already have used or disclosed your PHI in reliance on your consent.

May we fax and/or email to other providers if necessary for medical care.

Yes No N/A

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.

Signature of patient (or patient's representative)

Date:

Printed legal name of patient (or patient's representative)

Your information will be encrypted.