Thank you for your interest in Dana Group Associates!
The following documents are included:
Please complete EACH of the items. If the items do not pertain to you, please
answer “N/A.,” “none,” or put a dash through the answer box.
PCP Release of Information (ROI) (REQUIRED)
An ROI authorizes DGA to request, obtain and/
or exchange documentation with outside facilities. ***When requesting medical records, please note that
facilities legally have 21 days to process the request. For some cases, DGA cannot schedule an appointment
until we receive the requested records. Once we receive and review the requested records, we will contact you
with next steps.
*** PLEASE NOTE THAT MANY FACILITIES ACCEPT ONLY THEIR SPECIFIC
RELEASE OF INFORMATION FORM. PLEASE, CHECK THE FACILITY’S WEBSITE, OR
CONTACT THEIR MEDICAL RECORDS DEPARTMENT TO ENSURE THAT YOU ARE
COMPLETING THE CORRECT RELEASE FORM.
Consent to Treat (REQUIRED)
Authorizes DGA to provide treatment and/or take necessary actions to be able to provide treatment.
Financial Agreement (REQUIRED)
Responsibility of fees and charges for services provided by DGA.
Consent for Telemedicine Services (REQUIRED)
Authorizes DGA to use telemedicine in th
e course of your treatment.
ID and Insurance Card (REQUIRED)
Please provide a copy of your government issued ID and the front
and back o
Once completed please email the forms to email@example.com or to 781-465-7995 . If you fax any documents, please follow up with the intakes department by email or by phone to confirm our receipt of the documents. If you have any questions please contact our intake department by phone or email.
DGA Intake Department