Patient Privacy Form

In addition to my emergency contact, I authorize Statesboro Psychiatric Associates to talk with the following parties regarding my treatment and appointments:

Replace my Privacy Policy contacts

Add to my Privacy Policy contacts

Name:

Relationship:

Phone(H):

(W):

(C):

Address:

Name:

Relationship:

Phone(H):

(W):

(C):

Address:

Name:

Relationship:

Phone(H):

(W):

(C):

Address:

Name:

Relationship:

Phone(H):

(W):

(C):

Address:

I understand that in addition to other providers involved in my care, Statesboro Psychiatric Associates can provide treatment information to other providers for the purpose of coordination of care. This includes my primary care physician, referring physician, and other health care providers involved in my care.
In the case of a child, I understand that in many circumstances, a custodial parent or legal guardian other than the person bringing the child to appointments may have legal right to obtain the medical records of the minor.

Patient's Name:

Patient's Date of Birth:

Signature of Patient:

Date:

Signature of Parent/Guardian/Personal Representative:

Date:

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