AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION TO MARTIN G GREGORIO MD AND ASSOCIATES
AUTHORIZATION FOR USE/DISCLOSURE OF HEALTH INFORMATION TO MARTIN G GREGORIO MD AND ASSOCIATES
Please complete this field.
Please complete this field.
Please complete this field.
Authorization for Use/Disclosure of Information: I voluntarily consent to authorize my health care provider to disclose my health information during the term of this Authorization to the recipient(s) that I have identified below.
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Name: Martin G Gregorio MD and Associates
Address: 1500 Village Run Road, Suite 308 Wexford PA 15090
Fax: 724-934-3388
Phone: 724-934-1900
Purpose: I authorize the release of my health information for the following specific purpose:
Information to be disclosed: I authorize the release of the following health information: (check the applicable boxes below)
Please complete this field.
Term: I understand that this Authorization will remain in effect:
Please complete this field.
Please complete this field.
Redisclosure: I understand that my health care provider cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.
Please complete this field.
Please complete this field.
If Individual is unable to sign this Authorization, please complete the information below:
Please complete this field.
Please complete this field.
Please complete this field.
Please complete this field.
Thank you for subscribing!
You will receive important news and updates from our practice directly to your inbox.
Thanks!
Your form has been successfully submitted!
We will be in touch with you if additional information is needed.
Thanks!
Opt-out of using e-signatures?
Are you sure you want to opt-out of using e-signatures? You will be required to fill this form out again during your visit on a paper copy.
Download a copy of your signed form
Click the button below to download a PDF copy of your form