Updated Forms Only

Please correct the errors described below.

Disclosure of Medical/Financial Information to Friends or Family

(For Patients 18 years and older)

I, the undersigned, hereby authorize Dr. James R. Bond, Jr. and staff to disclose information from my medical or financial record to the following people:

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This authorization is give freely with the understanding that:

  1. This authorization is valid between January through December of year signed.
  2. May revoked in writing at any time but not retroactively.
  3. The facility, its employees, officers, and physician are hereby released from any legal responsibility of liability for disclosure of the information I authorized previously.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Please list current medications:

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** FOR ALL OUR PATIENTS 65 YRS OLD AND OLDER ONLY**

Primary Care Doctor or Family Doctor: (Please provide name and phone number)

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

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