PERSONAL HEALTH INFORMATION (PHI) DISCLOSURE FORM

  • Please list below any/all individuals (husband, wife, family, friends, guardian, doctors, etc.) that we may discuss your (PHI) Personal Health Information with, including but not limited to; treatment, diagnosis, appointment dates & times, billing, payments, etc.

    If you do not wish us to discuss your PHI with anyone please write NONE on any line below.

  • Click the + on the right to add more
    NameRelationship 
  • OR
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.
Please bring the printed materials for office visit or you can fax it to 989-793-7113 or 989-792-1792.