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By signing this consent form I acknowledge that a copy of the Notice of Privacy Practices of AccessMD Urgent Care has been offered/is available to me upon request.

Release of Medical Records:

I authorize AccessMD Urgent Care to release verbally, electronically, and/or in writing confidential medical information obtained during the course of my examination and/or treatment to any person or entity including my insurance carrier, employer (if treatment is related to employment), and/or other healthcare provider(s) for purpose of treatment, payment of charges, or quality assurances and utilization review. I understand that should I not choose to release my medical records to a specific entity and/or person(s), I must specifically state so in writing for inclusion in my medical record.


AccessMD is a fully equipped urgent care and occupational health center. Each Care Center is a full service facility with on-site X-rays, labs, EKG’s, medication dispensing.

Dayton | 937-528-2288
1010 Woodman Dr. Dayton, OH 45432

Miamisburg | 937-528-2286
8210 Springboro Pike Dayton, OH 45342

Greenville | 937-459-5389
1403 Wagner Ave. Greenville, OH 45331

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