PHI HIPAA Acknowledgement 2015 .pdf

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Please list below any person(s) we may disclose your PHI
Refer to section 1C (Uses and Disclosures of Your Highly Confidential Information).

Last Name, First Name

Relation to Patient

Last Name, First Name

Relation to Patient







Last Name, First Name



Relation to Patient



acknowledge and allow Pharmacy Benefits Manager on behalf of
(Patients/Guarantor Printed Name)

McLean County Foot and Ankle to access information from the national database for prescription and Allergy history.

Date of Signature

Signature of Patient/Guarantor

, 20 __________

I received McLean County Foot and Ankle Notice of Privacy Practices

Patient’s Printed Name

, 20___________
Signature (or Personal Representative*)

Date of Signature

Personal Representative’s Name (Printed)

Relationship of Personal Representative

* The Personal Representative is the patient’s decision maker if the patient cannot act for themselves. It can be the parent,
legal guardian, health care surrogate, or other person.

McLean County Foot and Ankle | 1404 Eastland Drive, Suite 104 | Bloomington, IL 61701 | (309) 662-9001

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