Revised:July26,2017

Permission to Speak Form

Patient’s Name: DOB:

Address: Home Phone:

Cell Phone:

SS#:

If the person signing this form is not the patient, please explain if you are guardian of the patient or have power of attorney for the patient. Documentation of this relationship may be required. I understand that this authorization shall remain in effect for 1 year from the date of my signature above unless (1) an earlier expiration date is specified in the space or (2) a written authorization with different instructions is provided after the date specified above. Records to be released: Please mark beside ANY applicable information to be released.

Note: If psychiatric/mental health, alcohol/other drug, or HIV/AIDS information is contained within the record(s), no part of the record(s) can be released unless the categories are marked appropriately.

Physician progress notes EKG Reports Psychiatric Mental Health Labs Operative Reports Appointment Information Radiology Reports Pathology Reports Alcohol and/other Drugs History and Physical Consultations Medicines Discharge Summary Diagnostic Imaging Dilated Retinal Eye Exam Other All of the above information (including any Psychiatric/Mental Health, Alcohol/Drugs, HIV/AIDS information) Dates of treatment: ** This does not entitle any other individual to pick up controlled substances for another party under any circumstances** The patient noted above gives permission to Coplin Health Systems to release the types of information marked above to the individuals whose names follow. For security purposes, these individuals MUST state their own date of birth to gain access to any of the information listed above: Name: Phone Number/DOB: Name: Phone Number/DOB: Name: Phone Number/DOB: ________ Name: Phone Number/DOB: Signature: ______________ Date: Witness: Date: