Hesham Fakhr, MD

Dear Patient:

In compliance with HIPAA regulations, Vein, Heart and Vascular Institute wants to protect your private health information.  We need to know the names of the people that you will allow us to discuss your medical information.

Please list below the names of the people that you will allow our staff and providers to talk to about your health and medical information; and sign your name to give permission. 

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Name                                                  Relationship                                   Phone Number

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Name                                                  Relationship                                   Phone Number

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Name                                                  Relationship                                   Phone Number

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Name                                                  Relationship                                   Phone Number

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Name                                                  Relationship                                    Phone Number

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Name                                                  Relationship                                   Phone Number

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Patient signature                                                                    Date

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Print Name							Date of Birth