Consent to Release Medical Information

Please correct the errors described below.


I give my consent for Margolin, Keinarth & Alberda, M.D. to discuss patient’s medical care and payment for medical care with the following people:

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  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.

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