Stephanie E. Siegrist, MD, LLC
980 Westfall Road • Suite 105 • Rochester, NY 14618
Phone: 585-271-4272
Fax: 585-730-6936
www.knowyourbones.com
We can only discuss or release your health information with you or people that you authorize (including spouse, parents,
etc…) Please list their names below.
PERMISSION TO DISCUSS/DISCLOSE PHI TO DESIGNATED INDIVIDUALS (optional)
The PRACTICE may disclose to a family member, relative, close personal friend or any other person identified by you
(the Designated Individual), your protected health information (PHI) directly relevant to that person’s involvement with
your care or the payment for your care. The PRACTICE may also use or disclose your PHI to notify or assist in notifying
(including identifying or locating) the condition or death. However, this can only occur if you agree to a disclosure to such
persons. If you wish to agree to such disclosures, please designate the persons you wish to be your Designated
Individual(s):
Name______________________________________________________ Relationship __________________________
Name _____________________________________________________ Relationship __________________________
Name _____________________________________________________ Relationship __________________________
Name _____________________________________________________ Relationship __________________________
Patient’s Name (please print):________________________________________________________________________
Signature of Patient/Legal Guardian: ____________________________________________ Date:__________________
687313507
10/12