Authorization to Release Medical Information to Family Members or Friends

This form does NOT authorize the release of electronic or paper copies of the medical chart

Patient Full Name:

Date Of Birth:

Sometimes our patients allow family members such as parents(s), grandparents, guardians, or close friends to call and discuss medical / billing information, request prescriptions, find out the results of labtesting, or double check doctor’s directions. With the exceptions discussed in our Privacy Practices found on our website we are not permitted to release your medical information to anyone without your consent. If you wish to have any of your medical information released to family members or friends, you must sign this form.

Please check one of the following

I DECLINE to have any of my medical information or billing discussed with family or friends.
I give my permission to MAPS For Recovery staff to discuss my ALL-health and billing information with the Individuals listed below.
I give my permission to MAPS for recovery staff to verbally disclose ONLY the following information with individuals listed below (Check all that apply)
Appointments ONLY
Labs including drug screen results
Labs NOT including drug screen results
Billing ONLY
Medications / medication directions

Other Please List:

Name:

Relationship:

I understand I must sign a separate authorization form releasing copies of my medical records to another individual or health care provider.
I understand I have the right to revoke my permission at any time except where Maps for Recovery has already made disclosures in reliance upon this request. I understand this permission remains in effect until the time I revoke it in writing.

Relationship to the Patient:

Date of Signature: