Consent Form 18 and Above

CONSENT FOR DISCLOSURE TO FAMILY MEMBER AND/OR DESIGNATED REPRESENTATIVE

Patient First Name

Patient Last Name

Birth Date:

I have agreed to let certain individuals participate in discussions and decisions related to my medical care. Therefore, I hereby give my permission for P.R.I.M.A. Inc. providers and staff to disclose my personal medical information to the following individuals:

Add Name

Conditions for Disclosure (check the item(s) that apply):

P.R.I.M.A. Inc. may disclose my medical information to the individual(s) listed above when I am not physically present, including disclosures by telephone, facsimile, or regular mail.

PLEASE NOTE:

P.R.I.M.A. Inc. will not disclose below listed confidential information without a specific release. In order to disclose any of these confidential information, please select one or more of these options.

I authorize the release of information relating to:

Alcohol/Drug Abuse Evaluation/Treatment

HIV/AIDS/STD Evaluation/Treatment

Psychiatric/Mental Health Evaluation/Treatment

Pregnancy Evaluation/Treatment

I understand that this consent may be revoked by me at any time by written notice to the practice and that I am responsible for informing the practice about any changes to the above information.

Patient initial:

Date:

Your information will be encrypted.