Patient Forms -Reliant Medical Group, Central MA Metro West

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Urgent Care

Reliant Medical Group Southboro Medical - Now a part of Reliant Medical Group (800) 283-2556 (508) 481-5500

Medical Records Release Authorization Form

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

Please click here to view Frequently Asked Questions about obtaining a copy of your medical records.

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
(300 Grove Street only)

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.

Authorization to Make Medical Decisions for a Minor

This form should be used if you have a family member or friend, who does not live with your child, who is assisting you by bringing your child in for medical care occasionally. By completing this form, you authorize the named individual to consent to care for your child on your behalf. This form expires after 60 days.

Caregiver Authorization Form

This form should be completed if an adult who is not the child’s parent or legal guardian, but who does live with and assist with providing care to the child, will be bringing the child to a medical appointment. This form will allow the named individual to consent to care for your child on your behalf, and expires after two years.

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.

Visual Patient History Form

This form is for new patients of Southboro Medical Group being seen in the visual department.