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Ali Medical, LLC
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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
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