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Consent Form Date:, 2016 To: Reconnect, Inc. 2012 Berry Chase Place Montgomery, Alabama 36117 Facsimile: (334) 2150448 Clinic Name: ORG Code: Re: Participation in Physician Quality Reporting System

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Step 1: Obtain a copy of the consent form from intranet.medisysinc.com.

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Step 2: Read through the entire form to familiarize yourself with its contents.

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Step 3: Fill out your personal information such as name, address, and date of birth in the designated fields.

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Step 4: Provide details about the purpose of the consent form and the specific actions or procedures being consented to.

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Step 5: If necessary, check any boxes or provide additional information related to specific limitations or restrictions on the consent.

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Step 6: Review the completed form for any errors or omissions and make any necessary corrections.

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Step 7: Sign and date the form at the bottom, indicating your full consent.

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Step 8: Submit the form as required, following any specified instructions or procedures.

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Step 9: Keep a copy of the filled-out consent form for your records.

Who needs consent form - intranetmedisysinccom?

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Anyone who is receiving or providing medical services or participating in any activities related to Medisys Inc. may need to fill out a consent form.

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This can include patients, healthcare providers, researchers, or any other individuals involved in the medical process.

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The specific need for a consent form may vary depending on the nature of the services or activities being undertaken.

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