HIPAA & Emergency Contact Information

Patient authorization to remove HIPAA and/or Emergency Contact
By signing this form, I authorize Altoona Ob/Gyn Associates, Inc., to remove the following from access to my Protected Health Information (PHI):

1)

Name(Required)
MM slash DD slash YYYY

2)

Name
MM slash DD slash YYYY

3)

Name
MM slash DD slash YYYY

Emergency Contact Person

If contact is same as above, please check here.

1)

Name
MM slash DD slash YYYY

2)

Name
MM slash DD slash YYYY

Patient Name(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.