Ann Shippy, MD - Publicforms

Available Forms

Authorization for Use and Disclosure of Protected Health Information Female Intake Form Informed Consent for Telehealth Consultations Insurance Policy Male Intake Form Medicare Private Contract New Patient Cancellation Policy New Patient Demographics Form New Patient Letter and Office Policies New Patient Supplement List Newsletter Form Notice of Privacy Practices PATIENT ENROLLMENT AND CONSENT FORM Permission to Disclose Medical Information Physician's Records Request List

Permission to Disclose Medical Information

I, *

Print patient's full name

Date of Birth *

grant permission to Ann Shippy, MD and employees the right to disclose and share my medical information by leaving messages on my voicemail. I acknowledge that in doing so I am waiving certain rights afforded to me under the Health Insurance Portability and Accountability Act (HIPPA).

I understand that I have the right to revoke this permission at any time, except for when after a disclosure has already been made.

Date *

I, *

Patient's full name

Date of birth *

grant permission to Ann Shippy, MD and employees the right to disclose and share my medical information with

Name

Full name

Signature *

Type your full name

I acknowledge that in doing so I am waiving certain rights afforded to me under the Health Insurance Portability and Accountability Act (HIPPA).

I understand that I have the right to revoke this permission at any time, except for when after a disclosure has already has already been made.

Recipient's Relationship to Patient:

Signature (Copy) *

Type your full name

Date *

* Required field