PHI ROI - Lock And Key Wellness

Lock and Key Wellness, LLC Permission to Discuss Protected Health Information (PHI) With Others Who are Involved in Your Wellness Care

I hereby permit Lock and Key Wellness to share specific information described below, only for the purposes and persons involved in my healthcare. Description of the specific information to be discussed:

Information provided

Description of the specific information to be discussed

Indicate Confidential Information you don’t want discussed

Information for provider:

Full name

Phone

Relationship with Client

Address

Address Line 1

Address Line 2

City

State

Zip Code

Consent for Treatment

It is my responsibility to inform Lock and Key Wellness of changes and to revoke and complete another form. I understand that:

This document does not dictate that our providers will initiate conversations or other methods to share information with persons listed above. If those persons wished to be involved, then it is their duty to initiate involvement, and if time and circumstances permit, then Lock and Key Wellness will do our best to comply to your wishes.
I may revoke this permission in writing by contacting our Privacy Officer.
Information shared may be subject to re-disclosure by the recipient and no longer be protected under HIPAA. This document is intended to relieve the burden of our staff to know to whom you want to involve in this client’s care. It is not mandatory to complete.
This document is not an authorization to release protected health information (PHI).

Client Printed Name

Signature

Clear Signature

Date

For clients under 18

Guardian Printed Name

Signature

Clear Signature

Date