Consent to use or disclose health information - Tower Hematology 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by authorizing Tower Hematology Oncology Medical Group (THOMG) to use and disclose your health information. Check the boxes for the specific permissions you wish to grant, such as a copy of your medical record or discussing your health with a designated individual.
3. If there are any exceptions or exclusions regarding what information should not be released, indicate them in the provided section. You can choose 'None' or specify other details.
4. Fill in the name and address of the person or institution you are authorizing to receive your health information. Ensure all fields are completed accurately.
5. Provide any additional instructions if necessary, and then proceed to sign the document. Include your printed name and date of birth for verification.

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