Designation for Release of Medical Information 2024

Designation for Release of Medical Information

Complete Foot and Ankle Specialists, LLC realizes there are times when you, the patient, may want another person to be knowledgeable about your medical condition or medical needs. If you would like to name a person whom you authorize our office staff to speak with about your medical condition, please complete the form listed below.

Please note, only one person can be designated for this role. The designation is valid until you cancel in writing.

I, the undersigned, designate the following person to be able to speak to a physician or staff member at Complete Foot and Ankle Specialists, LLC should it be necessary, on my behalf. I hereby give permission to Complete Foot and Ankle Specialists, LLC through its physicians and staff to release any information about my medical record.

By signing below, I understand this individual has the right to confirm, change, and cancel appointments as well as know all my past appointment history and past/present billing information.

Name of Designated Person*

Relationship*

Phone Number*

Please enter a valid phone number.

Type*

CellLandlineWork

Patient Name*

Patient Date of Birth*

Patient's signature*

Date*

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