Patient Information Release Consent
There are times when Community Health Centers (CHC), Inc. will need to contact you or when you may wish to allow family members and friends to have access to information concerning your medical care. Other than as allowed by federal law, we will not release any information to any person except as authorized below by you. Consent is valid unless revoked by the patient or legal guardian at any time.
Name of Patient
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Name of Consenting Person
*
First Name
Last Name
Relationship to Patient
*
Please Select
Self
Parent
Legal Guardian
Legal Custodian
Individuals Approved for Authorization
Please indicate the individuals, relationships, and the level of consent you'd like to provide.
(1) Name of Authorized
*
First Name
Last Name
(1) Relationship to Patient
*
Please Select
Parent
Spouse
Grandparent
Brother / Sister
Family Friend
Other
(1) Phone Number
*
Please enter a valid phone number.
(1) I authorize Community Health Centers to contact, share, or provide information to the individuals named in this consent form.
*
Appointments (dates, location, times, provider, reason)
Treatment (prescriptions, medication refills, diagnosis, procedures, etc)
Test and Procedure Results
Billing and Payment Information
Would you like to add an additional individual?
Yes
No
(2) Name of Authorized
*
First Name
Last Name
(2) Relationship to Patient
*
Please Select
Parent
Spouse
Grandparent
Brother / Sister
Family Friend
Other
(2) Phone Number
*
Please enter a valid phone number.
(2) I authorize Community Health Centers to contact, share, or provide information to the individuals named in this consent form.
*
Appointments (dates, location, times, provider, reason)
Treatment (prescriptions, medication refills, diagnosis, procedures, etc)
Test and Procedure Results
Billing and Payment Information
Would you like to add an additional individual?
Yes
No
(3) Name of Authorized
*
First Name
Last Name
(3) Relationship to Patient
*
Please Select
Parent
Spouse
Grandparent
Brother / Sister
Family Friend
Other
(3) Phone Number
*
Please enter a valid phone number.
(3) I authorize Community Health Centers to contact, share, or provide information to the individuals named in this consent form.
*
Appointments (dates, location, times, provider, reason)
Treatment (prescriptions, medication refills, diagnosis, procedures, etc)
Test and Procedure Results
Billing and Payment Information
Would you like to add an additional individual?
Yes
No
(4) Name of Authorized
*
First Name
Last Name
(4) Relationship to Patient
*
Please Select
Parent
Spouse
Grandparent
Brother / Sister
Family Friend
Other
(4) Phone Number
*
Please enter a valid phone number.
(4) I authorize Community Health Centers to contact, share, or provide information to the individuals named in this consent form.
*
Appointments (dates, location, times, provider, reason)
Treatment (prescriptions, medication refills, diagnosis, procedures, etc)
Test and Procedure Results
Billing and Payment Information
Signature
*
Date
*
-
Month
-
Day
Year
Date
All notices and agreements can be download from our
Patient Resources
page.
Consent Alignment Field (IGNORE)
Submit
Should be Empty: