Consent to Disclose Medical and Payment Information Post author By harreleyecare Post date April 12, 2023 Consent to Disclose Medical and Payment Information Patient Name Date of Birth Please CHECK one of the following: I give my permission to Harrel Eyecare doctors to disclose my Protected Health Information or payment to me AND the following friends or family: I request that all my Protected Health Information be disclosed ONLY to me and no other friends or family. Family Member or Friend Name Relation Signature of patient or guardian Date Relation if not signed by patient ← Cornea Transplant → Optomap Agreement Form
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