Permission for Physicians to Discuss Medical Information For patients 18 years and over

Patient Name:

Date of Birth:

Over the age of 18 your doctor is not allowed to discuss medical issues with your parents unless you agree. We will clear any discussion with you in advance. You are in control of which information we discuss. Be assured that any information which has been confidential in the past, will remain so.

I give permission for Burgess Pediatrics physicians to discuss my medical care with my parents as discussed above.

I do not authorize Burgess Pediatrics physicians to continue to discuss any of my medical care with my parents.

I authorize Burgess Pediatrics physicians to discuss my medical care with:

Name / Relationship:

I wish to exclude the following medical conditions from disclosure (if any) for example mental health, communicable diseases, alcohol/drug use:

I understand this authorization may be revoked by me at any time by notifying Burgess Pediatrics in writing.

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:

Date:

Your information will be encrypted.