By signing this consent form, I acknowledge that I have read, understand, and voluntarily consent to authorize the following:
Receipt of Privacy Practices:
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.