PERSONAL HEALTH INFORMATION (PHI) DISCLOSURE FORM

Patient Name*
Date of Birth*
Month
Day
Year
Please list below any/all individuals (husband, wife, family, friends, guardian, doctors, etc.) that we may discuss your (PHI) Personal Health Information with, including but not limited to; treatment, diagnosis, appointment dates & times, billing, payments, etc.

If you do not wish us to discuss your PHI with anyone please write NONE on any line below.
Individuals
Click the + on the right to add more
Name Relationship
Please initial if this authorization is permanent.
OR
This authorization expires on
MM slash DD slash YYYY
*
- I authorize and agree by checking this box and typing my name below
Your Name*
Your Email
Todays Date*
MM slash DD slash YYYY
Check the box below
Email
This field is for validation purposes and should be left unchanged.

Please bring the printed materials for office visit or you can fax it to 989-793-7113 or 989-792-1792.

Name	Relationship