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Release of Confidential Information Form

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Patient confidentiality is a priority at Prestige Medical Group. 
Therefore, it is important that you provide us with the following information to ensure your privacy

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In the event that I am unable to be reached, Prestige Medical Group has my permission to leave any test results or lab results in the following manner(s):

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May Call or leave message on voicemail at/on
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*Complete the information below to authorize release of information

*Complete the information below to authorize release of information

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IDO NOT GIVE Prestige Medical Group permission to release any medical records and billing information.

I GIVE Prestige Medical Group permission to release medical records and billing information to the following person(s):

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My Consent will remain in effect as long as I am a patient of Prestige Medical Group unless I notify Prestige Medical Group in writing of any changes. This authorization will remain in effect until a new Authorization is completed.

By signing below, I understand that I have read and understand the privacy practices for Prestige Medical Group. I also understand that I may obtain a copy either by request or by visiting PrestigeMedicalGroup.org.

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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