Ali Medical, LLC - Publicforms

Available Forms

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

REQUIRED-Consent to Obtain Medical Information from Other Providers / Entities

First Name *

Type your First Name

Last Name *

Type your Last Name

Date of Birth *

Please Provide Your Date of Birth

ALI MEDICAL, LLC is authorized to receive Medical Information from my other Medical Providers and other Entities *

I GIVE PERMISSION TO OBTAIN ALL MY MEDICAL RECORDS including information and records or copies of records relating to the history, diagnosis, treatment or services rendered to me in connection with any condition or disease. This includes permission to release POTENTIALLY SENSITIVE INFORMATION which may include information concerning my treatment of mental illness, Human Immunodeficiency Virus (HIV), alcoholism, drug use/dependency, venereal disease, sexual assaults, abortion, illegitimacy of birth, communications to social workers and/or psychotherapies, psychologists, if any.

Signature

Signature *

Please Type Your Name

Date Signed *

Please provide Today's Date

This Authorization expires AFTER one year from the date it was submitted.

* Required field