Permision to communication

Permission To Communicate

So that we may serve you better, you have the option of providing us with a list of people with whom we may discuss your health information. You are not required to provide a list. If no names are provided, our employees will not be able to discuss any issue related to your care with anyone but you..

Name:

Relationship:

give permission to Cochran Family Medical Center to share health information with the people listed below should anyone contact us for information. I understand this allows Cochran Family Medical to share any of my health and/or billing information. If I do not want certain information shared, I have listed it in the space below.

Do NOT release my information about:

give permission to Cochran Family Medical Center to use one of the following communication methods to provide information regarding my care. If not checked, a message to return our call will always be our normal method of communication when our office needs to relay information.

Leave a detailed message on my voicemail

Leave a message with:

I understand that I have the right to revoke this authorization at any time by giving Cochran Family Medical Center written notice. This authorization shall be in effect until revoked by the patient.

Signature:

Date:

Patient History Form

Printed Name:

Date of Birth:

Date:

Past Medical History

Other Diseases not listed above:

What surgeries have you had:

What other doctors do you see:

Family History Form

Paternal Grandfather:

Maternal Grandfather:

Paternal Grandmother:

Maternal Grandmother:

Do you use tobacco?

Yes No

How Often?

Do you use any street drugs?

Yes No

How Often?

Do you drink Alcohol?

Yes No

How Often?

Authorization For Release Of Medical Information

Patient Name:

Date of Birth:

Phone Number:

Address:

Request Records

Request Records From	Send Records To
Name of Practice/ Physician	Name of Practice/ Physician
Street Address/city/state	Street Address/city/state
Phone number Fax Number	Phone number Fax Number

I do NOT authorize release of information related to AIDS (acquired immunodeficiency syndrome) or HIV (human immunodeficiency virus) infection, sexually transmitted disease(s), psychiatric care and/or psychological assessment and/or treatment for alcohol and/or drug abuse.

I hereby authorize disclosure of the health information for the above named patient. This authorization is valid for 12 months from the date of signature. I understand that I may cancel this request with written notification but that it will not affect any information released prior to the cancellation. I understand that the information used or disclosed may be subject to re-disclosure by the person or facility receiving it and would then no longer be protected by this release. I understand the medical provider to whom this authorization is furnished may not condition its treatment of me on whether or not I sign the authorization.

Signature:

Date:

Cochran Family Medical
Center

Permission To Communicate

Do NOT release my information about:

Patient History Form

Past Medical History

Family History Form

Authorization For Release Of Medical Information

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