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WILMINGTON HEALTH
Patient Signature _____ Date/Time _____ Responsible Party Signature _____ Date/Time _____ AUTHORIZATION for USE and/or DISCLOSURE of PROTECTED HEALTH INFORMATION . I authorize the use and/or disclosure of my protected health information. I understand that this authorization is voluntary. I understand that, if the persons or organizations I ...
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PLEASE ANSWER ALL QUESTIONS PATIENT INFORMATION
www.wilmingtonhealth.comPlease return forms at least 3 days prior to your scheduled new patient appointment. Also, please request records from your former primary care doctors and any specialty doctors prior to your
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