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Please note the following specific requests: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Consent to Disclose Information
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Erickson Resource Group – [email protected] / www.ericksonresource.com t: 514-795-7377 EST ©2009 Erickson Resource Group - All rights reserved. No content contained within this document may be reused without
prior written permission.
Consent to Disclose Information Care Provider: ____________________________________________________ Address: _________________________________________________________ Phone: _____________________ Fax: _____________________________ Email: ___________________________________________________________ Patient: __________________________________________________________ Date of birth: _____________________________________________________ Medicare number: _________________________________________________ Social security/insurance number: _____________________________________ Insurance provider: ________________________________________________ I, ____________________________authorize __________________________ to disclose information to the following person(s):
1. ______________________________________________ 2. ______________________________________________ 3. ______________________________________________ 4. ______________________________________________ 5. ______________________________________________
This disclosure includes, but is not limited to: general health, diagnoses, treatment, medication, recommendations, and any other information that is important to my health status. Please note the following specific requests: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ I understand that I may revoke this consent in writing at any time. ______________________________________ ___________ Patient signature Date Disclaimer: This form may not be recognized as valid in some states or provinces. Check with your local legal offices for details.
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