Disclosures to Family Members and Friends

  • I,, the parent/legal of the following child/children:
  • Understand that disclosures may be made to family and friends related to the patient's health or as needed for payment for health care services. I understand that only information relevant to current treatment will be disclosed. I agree that health information can be disclosed to the following people: (please include individuals who may be calling our office, bringing the child in for treatment, picking up forms, etc. This might include stepparents, grandparents, babysitters, aunts/uncles, or family friends.)
  • Name Relationship Phone# Initials