Patient Authorization for Contact and Disclosure of Protected Health Information

Patient name:   Date of birth:   / /
This form allows our practice to release your medical information to the following contacts.
Your doctors are always informed so do not list them.
 
1. I authorize David Provost, MD to disclose my protected health information to:
List:  
List:  
2. I authorize the practice to disclose only the following protected health information to the individual(s) listed above:
3. I may be contacted with health information at the following numbers:
Home:   - - Cell:   - -
Work:   - -