PERSONAL HEALTH INFORMATION (PHI) DISCLOSURE FORM

Company
This field is for validation purposes and should be left unchanged.
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

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

Name	Relationship