PHI Release

PROTECTED HEALTH INFORMATION RELEASE FORM
Authorization for communication of Protected Health Information to Family Members and Friends
PATIENT NAME*
PATIENT'S DATE OF BIRTH*

MonthDayYear
I authorize the provider checked below to discuss/share protected health information about me with the following individual(s) who are involved in my care:
Provider Name:*

Joan Takacs, D.O.John Takacs, D.O.

List of Recipients

	Name	Relation	Phone No.
1.
2.
3.

Type of information to be shared or disclosed:*

All informationPrescription informationAppointment information
This authorization shall remain in effect until revoked in writing by the patient. Submitting a new form will revoke existing form.
SIGNATURE*

Clear
PATIENT/AUTHORIZED INDIVIDUAL*
Print Name
MonthDayYear
5909 SE Division Street, Portland, OR 97206

Office 503-234-1531 Fax 503-234-2367
Should be Empty: