Release and Use of Health Information
PATIENT AUTHORIZATION WAIVER FOR DISCLOSURE OF INFORMATION TO ANY WASHINGTON NEPHROLOGY ASSOCIATES ADMINISTRATIVE STAFF EMPLOYEE TO DISCUSS ANY MEDICAL CONDITION (S) WITH FAMILY MEMBERS OR DESIGNATED PERSON (S)
I am a patient of Washington Nephrology Associates, L.L.P. (WNA) and hereby authorize the support staff. I.e. secretaries, medical assistants, nurses, etc. to discuss my medical condition with the members of my family listed in the Registration Form.
The patient or the patient’s legal representative must read the following statements:
A. I understand that the provision of health care and the payment of health care will not be affected if this form is not signed.
B. I understand that I may revoke this authorization at any time by notifying Washington Nephrology Associates in writing, but it will not affect any actions taken by Washington Nephrology Associates prior to receiving the revocation.
Please initial and sign on Registration Form