Medical Records Release Authorization Form

This form will allow patients to authorize copies of their medical information to be released to person/facility named.

Patient Representative Release Authorization Form

This form will allow a patient to name a family member/friend/caretaker etc… to have verbal communication with your provider.

Authorization to Disclose Radiology Medical Record Information

This form will allow patients to authorize copies of their radiology images/reports to be released to person/facility named.

Health Care Proxy Form

This form will allow you to designate an individual to make health care decisions on your behalf in the event you become unable to make or communicate such decisions yourself.

Permission to Authorize Routine Examination and Treatment of a Minor

This form should be completed if an adult who is not the child’s parent or legal guardian, will assist with providing care to the child. By completing this form, you authorize the named individual to bring the child to a medical appointment and consent to care for your child on your behalf.

Notice of Privacy Practices (HIPAA)

This notice describes how medical information about patients may be used and disclosed and how patients can get this information.

Motor Vehicle Accident Insurance Information Form

This form should be completed if you were seen by us for a motor vehicle accident related injury, since you will not yet have claims information at the time of your visit.

Workers Comp Information Sheet

This form should be completed if you are seen for a work related accident.

Eye Services Patient History Form

This form is for new patients of Reliant Medical Group being seen in the eye services department.