Riverton Medical HIPAA Form

Riverton Medical

Name(required)

List any Medical Offices you allow Riverton Medical access. (e.g. Biorestoration Medical) *(required)

HIPAA Agreement: List any Email addresses which you allow personal medical information to be sent.

List any Phone Numbers which you allow personal medical information to be sent.

HIPAA Agreement: List family members, friends, medical offices, or personal which you wish to allow information to be accessed or sent.

I agree to allow my personal medical information to be stored and accessed by Riverton Medical PLLC, as well as others involved with coordination of care, such as pharmacies, hospitals, lab centers, and imaging centers, unless otherwise prohibited by you, as the patient, in writing.Sign electronically by entering your name below.(required)

Date(required)

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