Authorization to Release Medical Information to Family Members

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In accordance with Federal government privacy rules implemented through the Healthcare Portability Act of 1996 (HIPAA), for your healthcare provider or staff of Endwell Family Physicians LLP to discuss your condition with members of your family or other individuals that you designate, we must obtain your authorization prior to doing so. In the event of a critical episode or if you are unable to give your authorization due to the severity of your medical condition, the law stipulates that these rules may be waived.

By signing this form and listing names below, you are authorizing EFP to speak to these individuals about your medical care at EFP. You are not authorizing us to release written records to them. If you wish to obtain medical records, then please fill out the Authorization for Use or Disclosure of Protected Health Information.

Authorization

I do not authorize Endwell Family Physicians LLP to discuss any information concerning my medical care with any individual.

I authorize Endwell Family Physicians LLP to discuss any information concerning my medical care with the following individuals:

Name*

Relationship to Patient*

Phone*

Name

Relationship to Patient

Phone

Name

Relationship to Patient

Phone

Patient Name*

Email*

Date of Birth*

Patient Address*

Street Address * Address Line 2 City * State / Province * ZIP / Postal Code *

Emergency Contact Only Authorization
You may also wish to share your emergency contact information. Please note that listing someone only as an emergency contact does not allow us to discuss medical information under normal circumstances. We may only use this contact for emergency situations, unless you also have listed the person above.

Authorization

I do not want to list an emergency contact.

I authorize Endwell Family Physicians LLP to share my emergency contact information with the following individuals:

Name*

Relationship to Patient*

Phone*

Date*

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Patient Signature

Authorization to Release Medical Information to Family Members

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Practice Information

Patient Resources

Primary Care Services

Ancillary Services

Contact Us