CURRY HEALTH CENTER
THE UNIVERSITY OF MONTANA
634 Eddy Avenue
Missoula, MT 59812
Phone: 406-243-4330 Fax: 406-243-6949
PERMISSION TO VERBALLY DISCUSS
PROTECTED HEALTH INFORMATION
Patient Name
Date of birth
Street Address
City
Student ID Number
State
Zip
Phone Number (day)
I give Permission to Curry Health Center to VERBALLY discuss the following medical information about
me (check all boxes that apply):
Medical information, including my symptoms, diagnosis, medications and treatment plan
Medical billing information related to Curry Health Center charges and fees
Behavioral health information, including my symptoms, diagnosis, medications and treatment plan
Chemical Dependency information, including my symptoms, diagnosis, medications and treatment plan
Lab or X-Ray/test results
Only medical information related to: __________________________________________
Other (be specific)__________________________________________________________
Curry Health Center has my Permission to discuss the above information with:
Name: ________________________________________________
Relationship: ______________________
Address: ______________________________________________
City, State, Zip: _________________________________________
Phone: _____________________
Medical records are defined as: All health information, whether oral or recorded in any form or medium that
identifies the patient or can readily be associated with the patient and relates to the patient’s care. This includes
all health care information in your/our possession, whether generated by you/us or any other source, as well as
health care information associated with drug/alcohol abuse, mental or psychiatric care, abortion, and HIV status
an/or diagnosis of AIDS and /or other sexually transmitted diseases including hepatitis, unless restricted above.
I understand that this authorization may be revoked by me at any time, provided that I do so in writing and submit
it to the Medical Records Department, up to the extent that the disclosure has not already been made. I also
understand that my protected health information may be re-disclosed by the recipient and no longer protected
under federal law. Authorization will expire in 6 months unless otherwise specified.
Expiration Date: _____________________
Patient Signature ________________________________________________ Date _________________
or
Legal Representative/Guardian _____________________________________ Date _________________
Relationship to Patient ____________________________________
Office Use Only Information noted in Medicat
Date: _____________ By: ____________________
J:\General\Forms\Medical\Medical Office\Permission To Verbally Discuss.doc/Nov.2007/Rev.8/2011