Name: Scott Conkright
Address: 400 Plasters Ave N.E., Suite 150, Atlanta, GA, 30324, US
Telephone: 404-315-7150
Price range: $110

Release Of Information Consent Form

I Authorize

Dr. Scott Conkright
400 Plasters Ave N.E., Suite 150
Atlanta, GA 30324
Phone: 404-315-7150
Fax: 801-315-7150

All health information ( excludes information from a chemical dependency program & phycotherapy notes).

Purpose for disclosure: Coordination of care. I understand that: My health information is protected by federal regulation Alcohol & drug Abuse patient

Release Of Information Consent Form

I Authorize

Dr. Scott Conkright
400 Plasters Ave N.E., Suite 150
Atlanta, GA 30324
Phone: 404-315-7150
Fax: 801-315-7150

All health information ( excludes information from a chemical dependency program & phycotherapy notes).

Purpose for disclosure: Coordination of care. I understand that: My health information is protected by federal regulation Alcohol & drug Abuse patient

Here content?

Signature

Download the Form & Send it to

[email protected]

Release Of Information Consent Form

Name

Patient Signature

Patient Date Of Birth

Dates of Treatment

Record Offer

Num

Fax Num

Organization Name

Representative's Name

Representative's Relationship To Patient

Name

Address

City

State

Zipcode

Release Of Information Consent Form

I Authorize

All health information ( excludes information from a chemical dependency program & phycotherapy notes).

Release Of Information Consent Form

I Authorize

All health information ( excludes information from a chemical dependency program & phycotherapy notes).

Signature

Download the Form & Send it to

[email protected]

Release Of Information Consent Form

Download the form & send it to

[email protected]

Washington, D.C. Location

Atlanta Location