Forms to download and print in pdf format

Click on the form name to download a copy to your computer.

1. “A Statement of My Right to Medical Privacy”
2. “Authorization to Exchange Confidential Information”
3. “Collateral to Therapy Consent”
4. “Patient Request for Restriction on Use and Disclosure of PHI”
5. “Request for Amendment of Health Information 2”
6. “Revoking or Terminating Restrictions of Use and Disclosure of PHI”