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Mia Scott, DO Derek Miller, PAC Dana Chretien, PAC Wendy Wolf, PAC Loraine Van Slake, NP Charles Bi hum, AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION TO APEX FAMILY MEDICINEPatients Name:Date of
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Obtain a copy of the consent-to-release-medical-records-to-apex-new form.
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Fill out your personal information accurately, including your full name, address, date of birth, and contact information.
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Provide the name and address of the medical facility or individual who will be receiving your medical records.
04
Specify the types of medical records that you are authorizing to be released.
05
Indicate the date range of the medical records that you are authorizing to be released, if applicable.
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Sign and date the consent form
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Any individual who wants to authorize the release of their medical records to Apex New medical facility or individual needs consent-to-release-medical-records-to-apex-new.
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Consent-to-release-medical-records-to-apex-new is a form that allows a patient to authorize the release of their medical records to the medical facility Apex New.
Patients who wish to have their medical records released to Apex New are required to file consent-to-release-medical-records-to-apex-new.
To fill out the consent-to-release-medical-records-to-apex-new form, the patient must provide their personal information, specify the medical records to be released, and sign and date the form.
The purpose of consent-to-release-medical-records-to-apex-new is to authorize the release of a patient's medical records to Apex New for medical purposes.
The consent-to-release-medical-records-to-apex-new form must include the patient's name, date of birth, the medical records to be released, and any specific instructions or limitations.
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