Contact Removal Form - Altoona OB/GYN

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)

First Last

Date of Birth(Required)

Relationship(Required)

Home Phone(Required)

Cell Phone(Required)

Work Phone(Required)

2)

Name

First Last

Date of Birth

Relationship

Home Phone

Cell Phone

Work Phone

3)

Name

First Last

Date of Birth

Relationship

Home Phone

Cell Phone

Work Phone

Emergency Contact Person

If contact is same as above, please check here.

1)

Name

First Last

Date of Birth

Relationship

Home Phone

Cell Phone

Work Phone

2)

Name

First Last

Date of Birth

Relationship

Home Phone

Cell Phone

Work Phone

Patient Name(Required)

First Last

Date of Birth(Required)

Today's Date(Required)

Signature(Required)

This field is for validation purposes and should be left unchanged.