![Page 1: an Affiliate of Narendra R. Kumar, M.D., P · an Affiliate of Narendra R. Kumar, M.D., P.C PERSONAL HEALTH INFORMATION (PHI) DISCLOSURE FORM Today’s Date: _____ Patient Name: _____](https://reader036.vdocument.in/reader036/viewer/2022071020/5fd45c5a53471d47fa5e2a22/html5/thumbnails/1.jpg)
an Affiliate of Narendra R. Kumar, M.D., P.C
PERSONAL HEALTH INFORMATION (PHI) DISCLOSURE FORM
Today’s Date: _________________
Patient Name: __________________________________ Date of Birth: __________________
Please list below any/all individuals (husband, wife, family, friends, guardian, doctors, ect.) that we may discuss your (PHI) Personal Health Information with, including but not limited to; treatment, diagnosis, appointment dates & times, billing, payments, ect.
If you do not wish us to discuss your PHI with anyone please write NONE on any line below.
NAME RELATIONSHIP
___________________________________ ______________________________
___________________________________ ______________________________
___________________________________ ______________________________
___________________________________ ______________________________
___________________________________ ______________________________
Please initial if this authorization is permanent. __________ OR
This authorization expires on _________________, 20____.
Patient Signature: ___________________________________________________