Belleville_Permission_to

Permission to Discuss Confidential Health Information
DOB

MonthDayYear
Date
Pronouns

She/Her/HersHe/Him/HisThey/Them/TheirsOther
Name
Check all boxes that apply:

Scheduling/appointment informationMedical information, including symptoms, diagnosis, medications and treatment planBehavioural health information, including symptoms, diagnosis, medications andtreatment planChemical dependency, including symptoms, diagnosis, medications and treatment planLab and Test ResultsBilling and Payment InformationOther
Belleville Integrative Health Centre (B.I.H.C.) has my permission to discuss this information with the following people:
Physician
Physician Phone
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Specialist
Specialist Phone
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Family
Family Phone
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Other
Other Phone
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I understand that I may cancel this permission at any time, but that cancelling it will not affect any information that has already been released.

I understand that I do not have to sign this form, and that I should only sign if I want my medical provider or my clinic to share my information with someone.
I give permission to Belleville Integrative Health Centre (B.I.H.C) to discuss the following medical and billing information about me:
Patient Signature

Clear
Date

MonthDayYear
Date
Witness Signature

Clear
Date

MonthDayYear
Date
Should be Empty: