Special Confidential Handling of Health Information

SPECIAL CONFIDENTIAL HANDLING OF HEALTH INFORMATION

My Name Is:

First Name

Last Name

I AUTHORIZE YOU TO SHARE MY HEALTH INFORMATION WITH:

1. List each parent, guardian, or other adult with whom you authorize sharing of your medical information. 2. Indicate next to each name, that adult's relationship to you (e.g., parent, guardian, coach, etc.) 3. Provide the phone number, mailing address, and email address for each person named.

I AUTHORIZE YOU TO SHARE MY HEALTH INFORMATION WITH THE ABOVE-NAMED ADULTS UNDER THE FOLLOWING CIRCUMSTANCES:

Please explain any circumstances or conditions under which you authorize the provider to share your medical information with the adult(s) listed above.

ELECTRONIC SIGNATURE AND CONSENT

I understand that there may be times when I may provide the therapist with additional means for communication, outside of those listed above. It will be understood that these too will be considered patient-authorized confidential communications. Below is my electronic signature.

First Name

Last Name

Date Signed

YYYY