Get the free Page 4 - Fill out Notice of Privacy Practices and at time of visit, please ask

I also Name Signature Date RECORDS RELEASE AUTHORIZATION This record release authorization allows us to obtain and/or release your records to and from your primary physician and other physicians you are under the care of. Physician/Hospital Address Phone number ADVANCED DIRECTIVES Do you have an advanced directive in place Yes No If yes do you have Living Will Power of Attorney Healthcare Proxy DNR Please be advised if you do have any advanced directive our office is required to obtain a copy...

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