Permission to Relay Information

Please correct the errors described below.

As required by the Health Insurance Portability and Accountability Act of 1996 you have a right to request that communications concerning your personal health information be made through confidential channels. We will not ask why you are making your request, and will make reasonable efforts to accommodate all reasonable requests. Some method of contact must be provided, and as appropriate, information as to how payment will be handled.

I, (please indicate name on the box below) , give my permission for OC Women's Care Physician(s) and employees to communicate information related to my personal health, as indicated below. This request supersedes any prior request for communication of information I may have made.

Phone

You may use the following telephone numbers:

You may leave messages regarding my medical information with the following people (Print Names)& number:

Add Item

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

(Patient signature, if Patient is a minor then Parent or Legal Guardian must sign.)

Your message will be encrypted.