ACCORDIA HEALTH & WELLNESS INFORMED CONSENT FOR VERBAL / EMAIL EXCHANGE OF INFORMATION
I, , hereby consent to the verbal/ email exchange of information between Accordia Health and:
From my date of admission and for the following purpose:
If other please specify
I understand that this consent will expire Two years from the signature date or at the time of my discharge from this program, whichever comes first. I understand that I may revoke this consent at anytime. The revocation may be given verbally or in writing, and it will not apply to information that was discussed prior to my revocation of this consent.
I have been informed that copies of my medical record can only be released by my signing an authorization giving my permission to do so.