DOYLESTOWN THYROID AND ENDOCRINE ASSOCIATES

PATIENT AUTHORIZATION FORM

Authorization to Release Information to Family Members

    Many of our patients allow family members such as their spouse, significant other, parents or children to call and request the result of tests, procedures, and financial information. Under the requirements of H.I.P.P.A. we are not allowed to give this information to anyone without the patient’s consent. If you wish to have your medical information, any diagnostic test results and/or financial information released to any family members you must sign this form.

    You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

    I authorize Doylestown Thyroid and Endocrine Associates, LLC to release my records and any information requested to the following individuals.

    Relation to Patient:

    Relation to Patient:

    Relation to Patient:

    Authorization Regarding Messages

    (please check all that apply)

    Patient Name*
    Date
    Patients Signature*