AUTHORIZATION and CONSENT AGREEMENTAuthorization and Consent Agreement • December 1st, 2020
This consent form authorizes Premier Wellness Clinics to obtain and review my prescription history. Detailed prescription history provides your Medical Practitioner with information about medications being prescribed by other providers in your medical care. This information will improve the accuracy of our medication list in your medical chart and decrease any adverse drug reactions or inaccurate medication information such as drug names or dosages.
AGREEMENT FORMAuthorization and Consent Agreement • March 29th, 2017
AUTHORIZATION and CONSENT AGREEMENTAuthorization and Consent Agreement • November 24th, 2014
Thank you for reviewing our Financial and Office Policies and Notice of Privacy Practices. Please sign in the spaces provided below to acknowledge receipt of this information, and to enter your authorized contacts.
AUTHORIZATION AND CONSENT General ConditionsAuthorization and Consent Agreement • August 12th, 2004
Authorization and Consent Agreement, Assignment of Benefits, HIPAA, and other Healthcare OperationsAuthorization and Consent Agreement • May 6th, 2022
Thank you for reviewing our Financial and Office Policies and Notice of Privacy Practices. Please Initial the spaces provided below to acknowledge acceptance of this information.
