Consent to Release Medical Information

PATIENT’S READ AND SIGN AGREEMENT

1. I hereby give my consent for the physicians of Margolin, Keinarth & Alberda, M.D. to evaluate and treat the above patient.
2. I have been provided with the Privacy Practices Notice for Margolin, Keinarth & Alberda, M.D.
3. I understand that my personal health information will be used for the purpose of treatment, payment, and the coordination of health care needs of the patient.
4. I have also been provided and agree with the Financial Policy for Margolin, Keinarth & Alberda, M.D.

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