Medical Release
Dr. Tonya Cockrill | Dr. Emily Hung
Medical Release Information
I authorize Insurance Companies, Organizations, Employers, Hospitals, Physicians, Dentists, or Pharmacists to release any information requested with regard to processing my claim. I certify that the information I furnish is true and correct.
Signature
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Date:
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Month
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Day
Year
Acknowledgement of Review of Notice of Privacy Practices
I have reviewed Woodlands Arthritis Clinic PA Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.
Signature of Patient/Guardian
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Date
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Month
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Day
Year
Name
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First Name
Last Name
Relationship to Patient
Authorization to Release Medical Information to Individuals/Family Members
Please list those family members and healthcare providers to whom we may release your medical information.
Release Name 1
Release Name 2
Release Name 3
Release Name 4
I Do Not authorize Woodlands Arthritis Clinic to release any information to the following person(s):
Do Not Release 1
Do Not Release 2
Do Not Release 3
Do Not Release 4
Signature of Patient/Guardian
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Date
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Month
-
Day
Year
Patient/Guardian Name
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First Name
Last Name
Relationship To Patient:
Submit
Should be Empty: