Permission to Disclose Healthcare Information
Patient Name
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I hereby authorize North Bethesda Primary Care to disclose at its discretion....
*
ANY aspect of my healthcare information
only SOME of my healthcare information (PLEASE SPECIFY BELOW)
*
...to the following individual(s):
1.) Name
*
First Name
Last Name
Relationship
*
2.) Name
First Name
Last Name
Relationship
3.) Name
First Name
Last Name
Relationship
Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Authorized Representative (if not the patient)
First Name
Last Name
Relationship of Authorized Representative
Phone Number
Format: (000) 000-0000.
Submit
Should be Empty: