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SUBURBAN UROLOGIC ASSOCIATESACKNOWLEDGMENT OF RECEIPT OF NOTICE AND CONSENT TO USE AND DISCLOSE HEALTH INFORMATION Patient Name: Birth Date: This acknowledgment of notice and consent authorizes Suburban
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Gregory Halenda MD FACS is needed by individuals who require medical services or consultations in the field of surgery. This may include patients in need of surgical procedures, individuals seeking second opinions, or those looking for expert advice in surgical treatments.
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Gregory Halenda MD FACS is a medical doctor who is board certified in General Surgery and is a fellow of the American College of Surgeons.
Gregory Halenda MD FACS or his authorized representatives are required to file the necessary paperwork.
To fill out Gregory Halenda MD FACS, you must provide accurate and up-to-date information about his medical practice and qualifications.
The purpose of Gregory Halenda MD FACS is to provide documentation of his credentials, experience, and certifications in the field of surgery.
Information such as medical licenses, board certifications, hospital affiliations, and professional memberships must be reported on Gregory Halenda MD FACS.
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