Consent to Release Information This is an indefinite consent form

Consent to Release Information
Patient #
I,
, give the physicians and
office staff of mountain Region Family Medicine permission to discuss my medical condition
with:
With:
Who is:
Phone:
(Relationship)
With:
Who is:
Phone:
(Relationship)
With:
Who is:
Phone:
(Relationship)
With:
Who is:
Phone:
(Relationship)
I further give consent to share my medical record electronically with other physicians that I
may consult with and with the hospital where I may be admitted or have tests performed. I
understand these records will be transferred under the strictest HIPAA guidelines and no
financial or personal information will be shared.
Signature______________________________________________
May
May
May
May
no
we
we
we
we
confirm appointments by answering machine?
leave test results on you answering machine?
contact you at work?
look up your prescription benefits, only if there should be a need for this?
Patient Signature & Date of Birth
yes
Date
This is an indefinite consent form unless otherwise specified.