Use this form to authorize Hometown Health Centers to share your personal health information with someone you choose — for example, a family member, another provider, or a third party. Print and complete the form, then bring it to your visit or fax it to 518-395-9431.
What you type stays in your browser. Hometown does not receive or store anything you fill in here. Use the Print button to print a copy with your information, then bring or fax the printed form to us.
Consent to Disclose Personal Health Information
Hometown Health Centers · 1044 State Street, Schenectady, NY 12307 · (518) 370-1441
67 Division Street, Amsterdam, NY 12010 · (518) 627-2110
Authorization
I, (print your name), authorize (print name of health information custodian) to disclose:
(Describe the personal health information to be disclosed)
— or —
(Name of person for whom you are the substitute decision-maker*)
consisting of:
(Describe the personal health information to be disclosed)
To whom
To
(Print name and address of person requiring the information)
I understand the purpose for disclosing this personal health information to the person noted above. I understand that I can refuse to sign this consent form.
Patient
Patient Name
Address
Contact Telephone #
Signature
Date
Witness
Witness Name
Address
Telephone #
Signature
Date
* A substitute decision-maker is a person authorized under HIPAA to consent, on behalf of an individual, to disclose personal health information about the individual.