Patients up to age 18 should fill out this form.
Christian Family Medicine Inc. has provided me notification of its Privacy Practice for protected health information. I authorize Christian Family Medicine, Inc. the release of information including the diagnosis, records; examination rendered to me and claims information.
This Release of Information will remain in effect until terminated by me in writing.
Please indicate which relative has had the following diseases. Write in the number of siblings. For Disease and Conditions, use the comment box provided to list the age your relative got the condition if you know and whether this condition was the cause of death.
By checking this box on this online form, I certify that the information I’ve filled out above is correct.
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