Verbal Release Form 1. Check Authorization Type (one or both):1a. Telephone Messages: I hereby authorize Big Island Healthcare to leave a detailed message regarding my medical care on my voicemail, or with anyone answering the telephone. (Big Island Healthcare will use the phone numbers currently on file for you.) 1b. Authorized Person: I hereby authorize: Last Name, First Name Relationship to receive information verbally in person or via phone for:Patient Last Name(Required) Middle Initial Patient First Name(Required) Date of Birth MM slash DD slash YYYY 2. Complete disclosure type, sign, date (required): Disclosure Type: Verbal disclosure is authorized for any and all information about medical history, mental and physical condition, including HIV infection, AIDs, or ARC, drug and alcohol use, and other personal information unless otherwise specified: Summary(Required)Signature: I understand that I am authorizing Big Island Healthcare to verbally release protected health information to anyone answering the telephone numbers on file, or to the authorized person, including but not limited to medical care, insurance, and billing transactions. I, the requester/representative, have filled out this form completely. All blank fields are intentional. I understand that this authorization is voluntary, and that Big Island Healthcare will not condition my treatment or payment upon signing this form. This authorization is in effect until updated or revoked in writing.Patient or Parent/Guardian of Patient Email Date MM slash DD slash YYYY If signed by other than patient or parent of minor child, please print name below and indicate relationship.Legal Representative Relationship Date MM slash DD slash YYYY
