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Permission For Verbal Communications
Frequently Asked Questions

What is the Permission for Verbal Communications Form?
Should every patient fill out this form?
How many people can the patient designate?
Can a health care provider talk to others about the patient’s care, even if the patient did not complete the Permission for Verbal Communications form?
Who at Dean or St. Mary's Dean Ventures can discuss patient information with another person based on this form?
What information can be released based on this form?
Can the patient limit the type of information released by the health care provider?
Can copies of medical records be released based on this form?
What should a patient do after they have signed this form?
What if the patient no longer wants a designated person to communicate with their health care provider?

What is the Permission for Verbal Communications Form?

In some cases, a family member or friend may be closely involved in the care of the patient over a long period of time. This form allows patients to designate the family members or friends involved in the patient’s care. When the patient signs this form, they are indicating that clinical staff can speak with the individuals listed on the form about health care issues involving the patient.

Download the Permission for Verbal Communications Form (PDF)

Should every patient fill out this form?

No. Some patients may not want a health care provider to communicate with family members or friends about their medical condition. This form should only be filled out if the patient wants their health care provider to be able to talk to a family member or friend about the patient’s medical care. The form is a tool to help document the patient’s wishes. In most cases, the need for this type of communication will not be based on a one-time discussion between the health care provider and designated individual(s). Instead, it will involve many discussions which will take place over a long period of time.

How many people can the patient designate?

There is no limit to the number of people that the patient can designate as having permission to talk to the patient's health care provider. However, in most cases it will be limited to one or two very close family members or friends who routinely assist the patient with their medical care.

Can a health care provider talk to others about the patient's care, even if the patient did not complete the Permission for Verbal Communications form?

In many cases, a health care provider can talk to family members or friends even though this form has not been completed.
• If the patient is present, and has the capacity to object to the communication if they wish, and the patient does not do so, it is okay to talk to family members or friends about the patient’s care.
• If the patient is present and does not have the capacity to object, or if the patient is not present, the health care provider can exercise professional judgment and determine if the verbal disclosure of information is in the patient’s best interest.
• In cases of emergency, the health care provider can exercise professional judgment to determine if it is appropriate to communicate with others if it is in the best interest of the patient.
In situations where the patient has not expressly confirmed that the health care provider is allowed to communicate with a family member or friend, the information that is communicated should be limited to that information directly related to the person's involvement with the patient's health care.

Who at Dean or St. Mary's Dean Ventures can discuss patient information with another person based on this form?

Any health care provider, including physicians and clinic staff may discuss patient information with another person based on this form. Patient advocates, and business office staff may also discuss patient information with another person based on this form.

What information can be released based on this form?

Verbal information relating to the patient's medical care and treatment can be released to the people named on this form.

Can the patient limit the type of information released by the health care provider?

Yes. There is a section on the form where the patient can limit the type of medical condition the health care provider can discuss. In situations where the health care provider has exercised professional judgment and determined it is in the patient’s best interest to communicate with a family member or friend, the information that is communicated should be limited to that information directly related to the person’s involvement with the patient’s health care.

Can copies of medical records be released based on this form?

No. If the patient wishes to have copies of medical records released to another person, the patient must sign the standard Patient Authorization to Release Protected Health Information form.

What should a patient do after they have signed this form?

For All Dean clinic sites: The patient should give this form to their health care provider or to the Health Information Services Department at the site where they receive care.
For All St. Mary's Dean Ventures clinic sites: The patient should give this form to their health care provider or to the Medical Records Department at the site where they receive care.

What if the patient no longer wants a designated person to communicate with their health care provider?

For all Dean clinic sites: The patient should inform their health care provider that they no longer authorize communications with the designated person(s) about their medical condition AND send written verification of this fact to:

Dean Health System
Attention: Release of Information Specialist
Health Information Services
1313 Fish Hatchery Road
Madison, WI 53715

For all St. Mary's Dean Ventures clinic sites: The patient should inform their health care provider that they no longer authorize communications with the designated person(s) about their medical condition AND send written verification of this fact to the Medical Records Department at the site where they receive their care. Click here to find clinic locations.