Authorization to Discuss Medical | Pobletedermatology

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AUTHORIZATION TO DISCUSS MEDICAL INFORMATION WITH DESIGNATED PARTIES

PATIENT'S NAME

DATE OF BIRTH

I VOLUNTARILY REQUEST AND AUTHORIZE DR. MARIA ABELLO-POBLETE AND THE STAFF OF POBLETE DERMATOLOGY, TO DISCUSS AND RELEASE HEALTHCARE INFORMATION OF THE PATIENT NAMED ABOVE TO THE FOLLOWING:

PLEASE DESIGNATE FAMILY AND FRIENDS WITH WHOM WE CAN SHARE YOUR MEDICAL INFORMATION

WITH:

DESIGNATED PARTY:

DESIGNATED PARTY:

DESIGNATED PARTY:

RELATION TO PATIENT:

RELATION TO PATIENT:

RELATION TO PATIENT:

INITIAL: I understand that I can revoke this authorization at any time through a written request.

INITIAL: I understand that my treatment cannot be contingent upon my signing of this authorization.

PRINT PATIENT REPRESENTATIVE’S NAME

DATE

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