Consent Form to Disclose and Deletion of Patient Medical Information

Consent Form to Disclose and Deletion of Patient Medical Information

Request : *
Process to obtain patient information by: *
Someone charged with the authority of the patient means the rightful representative of a patient less than 20 years old unless they have a marriage certificate. The Legal Guardian has been assigned by court order.
Identity document
Upload Identity document
Maximum upload size: 67.11MB
Address
I acknowledge and understand that all medical patient information is confidential and secured by the BNH Hospital and will only be disclose by an authorized signature. Information that is collected by someone other than a BNH employee may be re-disclosed and no longer protected by the hospital. This consent form authorizes this person to proceed on my behalf.
Reason for request: *
Receiving by : *
I have received the patient medical information that I requested.