Patient Consent for Use and Disclosure of Protected Health Information "*" indicates required fields NameThis field is for validation purposes and should be left unchanged.I hereby give my consent for West Bend Family Medicine (Practice) to disclose and release my protected health information (PHI) as described below to the individual(s) identified. If no contacts are listed, the contact section should be left blank, indicating that West Bend Family Medicine is authorized to discuss my care only with me. “My care” includes, but is not limited to, appointment information, test results, follow-up care, and any other information related to me as a patient.Leave detailed messages on your voicemail? Yes No Contact #1 (optional)Name First Last RelationshipPhoneContact #2 (optional)Name* First Last RelationshipPhoneContact #3 (optional)Name* First Last RelationshipPhoneCheck ONLY if the answer is YES: Authorize the release of Alcohol and substance abuse to all contacts listed above? Authorize the release of Mental Healthcare to all contacts listed above? Authorize the release of HIV and STD to all contacts listed above? This authorization will remain in effect until changed in writing with the clinic.Email* Date* MM slash DD slash YYYY Name First Last Δ Back to New Patient Forms
