Ali Medical, LLC - Publicforms

Jump to Content

Available Forms

Payment Plan Authorization Form - Ali Medical, LLC REQUIRED-Consent to Obtain Medical Information from Other Providers / Entities REQUIRED-COVID19 Screening Form-ONLY For INPERSON Office Visits REQUIRED-Financial Responsibility Form REQUIRED-HIPAA Form - Sharing Health Information REQUIRED-New Patient Demographics Patient Medical History - Dr. Shereen - Rheumatology

REQUIRED-HIPAA Form - Sharing Health Information

First Name *

Type your First Name

Last Name *

Type your Last Name

Date Of Birth *

Please Provide your Date Of Birth

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

Please Indicate where we may leave a message if necessary: *

Home Answering Machine

Cell Phone Voice Mail Message

Work Phone Answering Machine

May we discuss your Medical Conditions with Family Members / Friends? *

Yes

No

if Yes then Please List Names of the Persons, Relationship and Phone Numbers

I give permission to Ali Medical to release information, either verbal or written regarding my medical condition only, for the purpose of: medical management and treatment, payment of my bills, and for issues concerning daily operations and responsibilities of Ali Medical. This release may be rescinded at any time in writing from the Patient/Legal Guardian.

Signature

Signature *

Please Type Your Name

Date This Form is Signed *

Please Provide Today's Date

* Required field