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Medical Records Documents Upload VALLEY NEUROLOGY GROUP
HIPPA SECURED PORTAL
Patient's Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Patient's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of Birth
If you wish to upload pictures or take Photos
File Upload
Browse Files
Drag and drop files here
Choose a file
HIPPA SECURED PORTAL
Cancel
of
Signature of the Patient/Care provider
*
Consent to give permission to use the infromation for Valley Neurology medical practice for healthcare purposes. Understand the HIPPA privacy information and limitations/ risk of sharing protected health information via online secure portal. The uploaded is responsible for understanding the risk/ use of online secure portal and its limitations and assume the responsibility of the risks involved. Also the uploader self or have discretionary rights to share the information of the above mentioned patient.
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