Test Page – Achieve Vitality

Patient - Disclosure Form

In general, the HIPAA privacy rule gives the individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.

First Name

Last Name

Contact Preferences

I wish to be contacted using the following methods. Please check all that apply.

Contact Methods

Home Telephone

Work Telephone

Written Communication

Home Telephone

If you chose Home Telephone, please choose one of the following :

It's OK to leave a detailed message.

Leave a message with our callback number only.

Work Telephone

If you chose Work Telephone, please choose one of the following :

It's OK to leave a detailed message.

Leave a message with our callback number only.

If you chose Written Communications, please choose one of the following :

Mail to my home address.

Mail to my work / office address.

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

Work / Office Address

Address Line 1

Address Line 2

City

State

Zip Code

Release Approval

I give permission to release protected health information to the following people.
( Please include their name, relationship to you, and phone number. )

Relationship #1

First Name

Last Name

Relationship

Phone

Relationship #2

First Name

Last Name

Relationship

Phone

Relationship #3

First Name

Last Name

Relationship

Phone

Signature

Sign Here

Contact Preferences

Release Approval

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