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PLEASE RETURN! THIS FORM IS GOOD FOR ALL TRIPS! Medical Consent/Media Release Form First Baptist Church, 3500 Walton Way Ext., Augusta, GA 30909 706.733.2236 www.fbcaugusta.orgNamePERMISSION CLAUSE:

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How to fill out medical consentmedia release form

01

Obtain a copy of the medical consent media release form from the healthcare provider or facility.

02

Read the form carefully and fill in all the required information such as the patient's name, date of birth, and contact information.

03

Sign and date the form to indicate your consent for the release of medical information and use of media.

04

If the form requires witness signatures, make sure to have a witness present to sign the form as well.

05

Keep a copy of the completed form for your records.

Who needs medical consentmedia release form?

01

Patients who are seeking medical treatment and wish to authorize the release of their medical information to specific individuals or entities.

02

Patients who are participating in media-related activities or events and are required to give consent for the use of their image or likeness.

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What is medical consent/media release form?

The medical consent/media release form is a legal document that gives permission to healthcare providers to disclose medical information or allows the use of a patient's medical information for specific purposes, such as media releases.

Who is required to file medical consent/media release form?

Patients or legal guardians of patients are required to file the medical consent/media release form.

How to fill out medical consent/media release form?

To fill out the medical consent/media release form, patients or legal guardians must provide personal information, sign the consent for medical information disclosure, and specify the purpose of use of medical information if applicable.

What is the purpose of medical consent/media release form?

The purpose of the medical consent/media release form is to obtain consent from patients or legal guardians for the disclosure or use of medical information for specific purposes.

What information must be reported on medical consent/media release form?

The medical consent/media release form must include personal information of the patient, details of the healthcare provider, consent for medical information disclosure, and purpose of use of medical information if applicable.

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