Follow the steps to successfully fill out the form.

1. Click the ‘Get Form’ button to access the Revised Consent Disclose - Simcoe Holistic Health form and open it in your preferred online editor.
2. In the first section, provide the full name of the patient or guardian as authorized. Ensure the name is printed clearly.
3. Next, specify the type of entity you are authorizing to disclose information. This may include a doctor, hospital, medical clinic, insurance company, or law firm.
4. Enter the contact details of the entity, including phone number and fax number. This information ensures proper communication regarding the consent.
5. Provide an email address for the entity to facilitate the sending of documents or clarifications if needed.
6. Describe the specific personal health information you wish to disclose. This may include records such as updated patient profiles or diagnostic imaging reports.
7. Indicate to whom the information should be forwarded, which in this case is Simcoe Holistic Health, including their address and contact information.
8. Acknowledge your understanding of the purpose of disclosing this information and any associated fees by checking the relevant acknowledgment box.
9. Provide the signature of the patient or guardian, ensuring it is signed on the designated line.
10. Include the date of signing on the specified line.
11. If applicable, print the name of the patient if you are signing as their guardian.
12. Fill in the patient's date of birth and ensure their telephone number is also noted.
13. Complete the form by saving your changes. You can then download, print, or share the form as necessary.

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