Designation for Release of Medical Information

Complete Foot and Ankle Specialists, LLC realizes there are times when you, the patient, may want another person to be knowledgeable about your medical condition or medical needs.If you would like to name a person whom you authorize our office staff to speak with about your medical condition, please complete the form listed below.

Please note, only one person can be designated for this role. The designation is valid until you cancel in writing

I, [Enter Name Below] designate the following person to be able to speak to a physician or staff member at Complete Foot and Ankle Specialists, LLC should it be necessary, on my behalf. I hereby give permission to Complete Foot and Ankle Specialists, LLC through its physicians and staff to release any information about my medical record.

Name of Designated Person:

Relationship:

Cell Phone:

Where do you use your phone?

Home Cell Work

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

Patient Signature:

Date:

Your information will be encrypted.