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Consent to Disclose Information

DE M O

Care Provider: ____________________________________________________ Address: _________________________________________________________ Phone: _____________________ Fax: _____________________________ Email: ___________________________________________________________ Patient: __________________________________________________________ Date of birth: _____________________________________________________ Medicare number: _________________________________________________ Social security/insurance number: _____________________________________ Insurance provider: ________________________________________________ I, ____________________________authorize __________________________ to disclose information to the following person(s): ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________ ______________________________________________

A

1. 2. 3. 4. 5.

IS

This disclosure includes, but is not limited to: general health, diagnoses, treatment, medication, recommendations, and any other information that is important to my health status.

TH

IS

Please note the following specific requests: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ I understand that I may revoke this consent in writing at any time.

______________________________________ Patient signature

___________ Date

Disclaimer: This form may not be recognized as valid in some states or provinces. Check with your local legal offices for details.

Erickson Resource Group – stephanie@ericksonresource.com / www.ericksonresource.com t: 514-795-7377 EST Š2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without prior written permission.

Consent to Disclose Information  

This form is to be given to each care provider involved in your aging parent or loved one’s care. It allows for your aging parent or loved...

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