Information sharing consent form

Below is the form you will be asked to sign if you would like a trusted individual to have access to your medical information:

 

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I, _______________________________ (patient name) hereby authorize _________________________ (trusted individual full name), my _______________(indicate relationship) to have full access to my medical chart, book appointments on my behalf, and obtain medical information as needed. This authorization includes:

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• Viewing my medical records and history

• Discussing my condition, treatment plans, and any other health-related information with healthcare providers

• Receiving copies of medical reports, diagnoses, and test results

 

Effective Date and Expiration:

This authorization is effective immediately and indefinitely, unless otherwise revoked in writing by me.

 

Right to Revoke:

I understand that I have the right to revoke this authorization at any time by providing a written notice to the healthcare provider. I am aware that the revocation will not affect any actions taken prior to the receipt of the notice.

 

By signing below, I acknowledge that I have read and understand this consent form and agree to its terms. I also certify that I am of legal age and have the legal authority to grant this authorization.

 

Patient’s Name____________________

 

Signature_________________________

 

Date___________________________

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