Additional Consent For Disclosure
Of Medical Information

Patient Information

West Tennessee Bone & Joint Clinic, P.C. realizes you may wish to have a family member or close friend present at times when health information is discussed with you, such as the time of your office visit, prior to and after surgery, discussing test results etc.

We realize the importance of protecting your privacy. This authorization gives the above Clinic and Staff your consent to disclose personal health information about you to your family, close personal friends, or any person that you identify, as long as the information disclosed to those individuals is relevant to the involvement in your treatment, payment or healthcare operations. The above listed Clinic may notify a family member or another person who is responsible for your care of your location and general health condition.

This form also provides you with the opportunity to choose not to have your health information disclosed to individuals in your care. You must return this form if you wish to opt-out of such disclosures.

Please select one of the following to indicate your choice regarding such disclosures: