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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

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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