Disclosure Authorization Form - South Coast Neurology

South Coast Neurology

Disclosure Authorization Form

I, , hereby PERMIT the providers of South Coast Neurology, Inc. to disclose my health care prognosis only to the family members listed below. I understand that this authorization is voluntary.

Name

Relationship

Name

Relationship

Name

Relationship

Print Name

Date

Signature

Witness Signature

OR

Check this box if you DO NOT PERMIT South Coast Neurology, Inc. to discuss your health care prognosis to any family member

Print Name

Date

Signature

Witness Signature

2323 De La Vina Street, Suite 209, Santa Barbara, CA 93105 Tel: (805) 220-4300