HIPAA Consent for Patient Information Release

I Authorize The Healthy Cocoon Practiceto release my personal health information to family members or others involved in my care or assisting me with financial payment arrangements.

Privacy Information

Please select one option from the following statements. By selecting one for the following statements this office will leave voicemail or answering machine messages at your home, work or emergency contact on file that may include your protected health information and that may be overheard by others not involved in your care.

This form will remain in effect for One Year from the date of signature. Any changes to this form must be submitted on a new form by the patient and witnessed.