Medical Consultation

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Medical Consent Forms

HIPAA, Records Release & Authorization to Treat
Authorization to Release Medical Records
I request and authorize The MD Specialists to release my healthcare information to whom they deem necessary. This request and authorization applies to:*

Healthcare Information in relation to the following treatment, condition, and dates relating to treatment at The MD Specialists.All Healthcare InformationI authorize the release of any records regarding drug, alcohol or mental health treatment to the person(s) listed above.I do not authorize The MD Specialists to release any medical records to anyone.
THIS AUTHORIZATION EXPIRES ONE YEAR AFTER ITS SIGNED.
Consent for Treatment Authorization
I authorize The MD Specialists’s medical provider, to perform the medical treatment/procedure(s) and/or diagnostic procedures, as may in their professional judgement be necessary to provide for the medical or emergency care. I have been informed of the reasons for the medical treatment/procedure(s), along with the expected benefits, risks, possible alternative methods of treatment, and possible consequences involved. I further give consent to The MD Specialists’s medical provider to arrange for routine or emergency medical and medical treatment if necessary to preserve my health. In the event that I am injured or ill while under the care of the The MD Specialists, I hereby give permission to the Medical Provider to provide first aid and to take appropriate measures, including contacting the Emergency Medical Service(EMS) system and arranging for transportation if necessary. In making medical decisions, I direct that the Medical Provider attempt to contact me. However, if medical care becomes essential, I give permission to the medical provider to make sure decisions regarding such medical treatment as deemed appropriate by the medical provider, hospital, or authorized designee. In furtherance of any medical treatment decisions to be made by the Medical Provider on my behalf for my benefit. I authorize The MD Specialists's medical provider to request, obtain, review and inspect any and all information bearing health and relevant to any such decisions to be made respecting such medical treatment. I also certify that no guarantee or assurance has been made as to the results that may be obtained.I have read, understood and agree with The MD Specialists Terms, Conditions, Policies and Procedures clearly stated on their website including, HIPAA Data Privacy.
Date*

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Rapid Covid Test

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PCR Covid Test

$150.00 Quantity

Medical Consultation

$30.00 Quantity

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Medical Consent Forms

Authorization to Release Medical Records

Consent for Treatment Authorization

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