GROVETON FAMILY MEDICAL PATIENT PORTAL

Groveton Family Medical

180 North Magee Groveton, TX 75845 Phone: 936-642-0841 Fax: 936-309-0086

Limited Release of Information to Family/Friends for Clinic

Patients first name * Last name * DOB *

I give my permission to my physician practice that is part of the Groveton Family Medical clinic to share certain personal health information about me with the individual(s) listed below. The individual(s) will only be given information about me that is related to their involvement in my care or payment for my care**. I understand I am not required to complete this form to obtain health care.

I give my permission to talk to this person about (check each that applies):

Person 1: Phone number Relationship to patient I give my permission to talk to this person (#1) about (check each that applies): Other Person 2: Phone number Relationship to patient I give my permission to talk to this person (#2) about (check each that applies):

If I change my mind about the people of the contact information I have listed in this form, I will complete a new form with such changes.

Signature of Patient or Authorized Representative Relationship to Patient Todays Date

** This form is not a substitute for a health care power of attorney or other formal designation of an Individual Authorized to make healthcare decisions for you If you are not able. If an Individual listed above Is your guardian or agent (under a power of attorney), or is otherwise authorized by law to act on your behalf, your health care provider may share as much of your personal health information with that person as the law permits This form is not a substitute for a valid HIPAA compliant written authorization When It Is required to release copies of medical and billing records or Information.