Help us understand your health to provide personalized, effective care.
So that we may serve you better, you have the option of providing us with a list of people with whom we may discuss your health information. You are not required to provide a list. If no names are provided, our employees will not be able to discuss any issue related to your care with anyone but you.
Give permission to Cochran Family Medical Center to share health information with the people listed below should anyone contact us for information. I understand this allows Cochran Family Medical to share any of my health and/or billing information. If I do not want certain information shared, I have listed it in the space below.*
I understand that I have the right to revoke this authorization at any time by giving Cochran Family Medical Center written notice. This authorization shall be in effect until revoked by the patient.
I do NOT authorize release of information related to AIDS (acquired immunodeficiency syndrome) or HIV (human immunodeficiency virus) infection, sexually transmitted disease(s), psychiatric care and/or psychological assessment and/or treatment for alcohol and/or drug abuse.*
I hereby authorize disclosure of the health information for the above named patient. This authorization is valid for 12 months from the date of signature. I understand that I may cancel this request with written notification but that it will not affect any information released prior to the cancellation. I understand that the information used or disclosed may be subject to re-disclosure by the person or facility receiving it and would then no longer be protected by this release. I understand the medical provider to whom this authorization is furnished may not condition its treatment of me on whether or not I sign the authorization.
