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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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