The federal Law requires that we make every effort to inform you of your rights related to your personal health information. Please check only one below.
Consent to Leave
If we are unable to speak with you directly, we may need to leave a voice mail/answering machine message or a message with a family member or others who answer your telephone. This message may include detailed information about your child’s condition or treatment, such as test results or the scheduling of procedures. Please check one:
Financial Assignment & Medical Release
DISCLAIMER: By typing your name(s) below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
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