Patient Authorization To Discuss

Protected Health Information (PHI)

FORM 007

The following named individuals have permission to discuss my PHI with my healthcare providers(s) and/or his office staff as my medical condition may require. This includes, but is not limited to, appointments, treatment plans, laboratory and diagnostic studies; and other information related to my medical care, including alcohol and drug abuse, psychiatric care, HIV and AIDS.

Person(s) authorized by patient to discuss PHI