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Home
Our Office
Medical Team
Admin / Front Office
Forms and Handouts
Patient Information Sheet
Request For Medical Records
HIPPA Form
Past Medical History
Contact Us
Medical Reference Sites
The Local Community
HIPPA Form
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Birthdate
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Social Security #
I understand that as part of my healthcare, this organization originate and maintains health records describing my health history, symptoms, examination and test result, diagnoses, treatment and plans for further care or treatment, give my authorization to my physician/physician's staff to discuss my medical issues concerning me to:
Name
First
Last
Name (copy)
First
Last
Name (copy) (copy)
First
Last
Name (copy) (copy) (copy)
First
Last
I,
,also give my physician/physician's staff permission to leave a message on my home answering machine or to any person answering my home phone
I,
,also give permission to my physician/physician's staff to contact me at my place of employment. If I am unable to be reached there, I give permission to my physician/physician's staff to leave a message for me to return their call
If there is any medical information I do not want to be discuss or a message to be left on my home or at my place of employment, I will notify my Physician/physician's staff of this in writing. If there is any change in information pertaining to this consent, I will also notify my Physician/physician's staff of this in writing
I,
,also give permission to my physician/physician's staff to fax any information regarding me to another physician's office that may be covering for my physician/physician's staff or a physician I may be referred to be my physician/physician's staff.
I have had the chance to read and thing about the consent of this authorized form and I agree with all statement made in this authorization. I understand that by signing this form, I am confirming mu authorization for use and/or disclosure of the protected health information described in this form with the people and/or organization name in this form.
Signature Of Patient Or Legal Representative
Clear Signature
Witness Signature
Clear Signature
Date
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I acknowledge receipt of the notice of privacy practice form which detail how protected health information may be used and disclosed, And how I may access that information
Signature Of Patient Or Legal Representative
Clear Signature
Witness Signature
Clear Signature
Date
MM
1
2
3
4
5
6
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8
9
10
11
12
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DD
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18
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21
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29
30
31
/
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
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1969
1968
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