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Patient Forms · Privacy & records

Permission to Share Information

Tell us which family members or others we may talk to about your care, what we may discuss with each, and what messages we may leave — about 4 minutes.

Send it online when you finish, or print it and bring it to your visit. What you send goes securely to our office’s patient system. Nothing is sent until you press Send, and nothing you type is saved on this device.

Start Print a blank copy (opens in a new tab)

Urological Consultants of Florida
12411 Biscayne Boulevard, North Miami, FL 33181 · (305) 672-4222 · www.miamiurologyconsultants.com

Permission to Share Information with Family or OthersSHARE-1 · v2026.11.0

Permission to Share Information with Family or Others

About 4 minutes · SHARE-1 · v2026.11.0

All fields are required unless marked (optional).

About you

MM/DD/YYYY

People we may talk to about your care

List up to three people. We will share only what you tick for each person, and only what is relevant to their involvement in your care or payment.

Person 1
What we may discuss with this person
Person 2
What we may discuss with this person
Person 3
What we may discuss with this person
Phone messages
Your mobile phone: if you don't answer, we may…
Your home or other phone: if you don't answer, we may… (optional)
Your work phone: if you don't answer, we may… (optional)
Preferred way to reach you
Your choices

PERMISSION TO SHARE HEALTH INFORMATION WITH FAMILY OR OTHERS

I agree that Urological Consultants of Florida may share my health information with the people named on this form, limited to the topics I have checked for each person and to what is relevant to that person’s involvement in my care or payment for my care.

This permission stays in effect until I change or cancel it. I can change or cancel it at any time by telling the office in person, in writing, or by calling (305) 672-4222. A change does not affect information already shared.

This form does not allow the practice to send copies of my medical records to anyone. To do that, I will sign a separate Authorization to Release or Request Medical Records.

My treatment does not depend on whether I sign this form.

Signature
Who is signing?

For example: parent of a minor; court-appointed guardian; health care surrogate; power of attorney. Please bring a copy of the document that gives you authority.

Signature of patient or personal representative

Review and send

When you have finished, send your answers to our office. Nothing is sent until you press Send to the practice. You can also print your form and bring it instead.

Sent securely to our office’s patient system. This page does not save what you type on this device.

What to bring to your visit

  • Photo ID
  • Your insurance card(s)
  • Your medication list or bottles
  • Any referral or recent records, if you have them

Questions? Call (305) 672-4222, Monday–Friday, 9:00 am – 5:00 pm.