Authorization to Release Protected Health Information

Your health information is protected (PHI, Protected Health Information) by HIPAA Privacy Rules. At times, you may wish to release your PHI to a parent, child, family member, or caregiver.

In order for us to release this information, we need your written consent. Please indicate below the names and relationships of those with whom we may discuss your care, including scheduling appointments, your account, and the details of your treatment plan.

**If you are over age 18 and still covered on your parents’ insurance plan, we will assume that we may discuss your PHI, including financial account, treatment plan, and scheduling details with your parent(s)/responsible party, unless you indicate otherwise.