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Dr. Dana Simpson MD 679 Orangeburg Rd Suite F Summerville SC 29483 Phone 843-261-2600 Fax 888-839-6837 Authorization to Release ATR Information / In Case of Emergency ICE Contacts Patient Name Date of Birth I authorize the release of healthcare information to the following individuals for assisting in my care-taking and/or in case of emergency. Name Phone Number 1 ATR Yes ICE No Relationship to Patient Address is same as patient s. Address Yes No This request applies to All/or healthcare...

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1. Gather all relevant information such as personal details, medical history, and insurance information.
2. Visit the official website of Dana Simpson MD or go to the clinic in person.
3. Request a patient registration form from the reception or find the online registration section on the website.
4. Fill out the registration form accurately and completely.
5. Provide all the required details, including your name, date of birth, address, contact information, and emergency contact.
6. Enter your medical history, including previous diagnoses, medications, allergies, and surgeries, if applicable.
7. Provide your insurance information, including the name of the insurance company and policy number.
8. Review the form for any errors or omissions before submitting it.
9. Submit the filled-out form to the receptionist or follow the online submission process.
10. Wait for confirmation of your registration and keep a copy of the filled-out form for your records.

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1. Anyone seeking medical care from a qualified physician can visit Dana Simpson MD.
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