Consent to Communicate - Dr. Boris A. Khaimov, D.O.

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Patient Information

Patient First Name*

Patient Last Name*

Birth Date*

Maiden or Other Name (if applicable)

Release / Receive Information

I request and authorize Dr. Khaimov to release / receive the health care information described below to / from:

Name*

At Phone #*

Address*

City, State*

Zip Code*

Please Initial to Specifically Authorize the Use and/or Disclosure of:

Enter your initials next to each item you authorize.*

Leave an item blank if you do not authorize it.

Emergency Room/Urgent Care Records

Admission Note

Hospital Records (nursing and progress notes)

Discharge Summary

Initial Psychiatric Evaluation

Clinical Summary

Medication History

Outpatient Progress Notes

Psychological Test Report

Consultation Report (specify in other)

Laboratory Reports (specify in other)

X-ray Reports (specify in other)

Billing Statements

Verbal Discussion of Case

Other:

Section

The requested records or information is about health care provided during the following approximate time frame: One Year

I understand that, unless action already has been taken in reliance on this authorization, I may revoke this authorization at any time by making written request to Dr. Boris Khaimov.

I understand that information disclosed based on this authorization may be subject to redisclosure by the recipient, and no longer protected by federal privacy regulations.

I understand that my express consent is required to release any health care information relating to testing, diagnosis and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders/mental health or drug/alcohol treatment or use.

Signature (patient or authorized representative)*

Writing out your name is proof of signature.

First Name*

Last Name*

Signature preview

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Date*

Relationship/Authority (if signed by authorized representative)

Email address to send a copy of this signed authorization*

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Thank you

Your consent to communicate form has been received.