Patient Disclosure Authorization

Use this form to authorize our practice to share your medical information with specific individuals, such as a spouse or family member.

I authorize disclosure of my protected health information only in the specific manner, for the named reason, and to the specific individual(s) described below.

Patient Information

First Name *

Last Name *

Date of Birth *

Disclosure Details

Specific description of information to be used or disclosed *

Reason for requested use or disclosure *

Authorized Individuals

Name of person(s) to whom this practice may give my medical information.

Person 1: Name *

Person 1: Relationship *

Person 2: Name

Person 2: Relationship

Person 3: Name

Person 3: Relationship

Signature

Sign below using your mouse, trackpad, or finger.

Type your full name *

Today’s date *

Prefer to complete this on paper? Call us at (203) 822-6749 and we’ll be glad to help.

Patient Disclosure Authorization

Your Health.Our Priority.

Your Health.
Our Priority.