Patient Information
Parent/Guardian Information Person who is legally responsible for above person
Insurance Information

Primary Insurance

$

Secondary Insurance

$
Patient Responsibilities Notification
Patient Disclosure Authorization

Christian Family Medicine Inc. has provided me notification of their 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.