consent-for-verbal-form – aedoctors

Tina Bansal, MD
800 E Woodfield Rd, Ste 113. Schaumburg, IL 60173
Phone: 847-686-6866 Fax: 847-706-9891

Consent For Verbal Release Of Information

Patient Name: Date Of Birth:

Primary Phone Number: HOME WORK CELL

: YES, leave a DETAILED MESSAGE. I understand this may regard all aspects of my health care. Including but not limited to: Lab or imaging test results, medication changes and treatment plans.

**PLEASE NOTE: If you do not have your full name on your outgoing message, we cannot leave any details, regardless of consent. Please consider changing your outgoing message if your full name is not stated.**

: NO, do not leave any details. I will call back to receive the message.

Please list any person(s) with whom we MAY share details about your health care. Please note: This may include sensitive health information (SHI) such as mental health, developmental disabilities, AIDS/HIV or other STD treatment and/or diagnosis, Drug/Alcohol abuse diagnosis, treatment plans, medication changes, lab/imaging results, referrals and Genetic Testing.

Name: Relationship:

Phone Number:
Leave Detailed Message:

Name: Relationship:

Phone Number: Leave Detailed Message:

Name: Relationship:

Phone Number: Leave Detailed Message:

I understand that consent is valid until it is revoked by me and applies to information about me obtained through any and all Advanced Endocrinology, LLC locations and providers or staff. I understand that I may revoke this consent at any time by giving written notice of my desire to do so to Advanced Endocrinology, LLC. I also understand that I will not be able to revoke this consent in cases where the provider or staff has already relied on it to use or disclose health information. Written revocation of consent must be sent to the physician’s office.



Printed Name: Relationship to Patient: