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For your convenience, we now offer payment plans through CareCredit. Please see our Online Payments page to apply online for this financing option, prior to your appointment.
With my digital signature below, I consent to the release of the above listed information / documents.
This authorization will expire 1 year from 01/31/2023.
I understand I may withdraw my authorization at any time by submitting a written request to the HIPAA Privacy Officer. I understand any revocation is not effective to the extent action has already been taken in reliance on this authorization. I understand information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by federal or state law. This authorization is not intended to affect a patient's ability to receive medical care.
Alcohol and Drug Abuse Treatment.
To the extent my medical record contains information regarding alcohol or drug treatment that is protected by federal law, I authorize the disclosure of such information or record.
HIV / AIDS Information
To the extent my medical record contains information regarding my HIV/AIDS status, treatment or testing, I authorize the disclosure of such information or record.
Behavioral Health Notes / Record
I authorize the disclosure of any behavioral health notes or information in my medical record.
Community Partner site to email this completed form to firstname.lastname@example.org. Midwestern will
contact the patient to schedule an appointment within 48 business hours of receipt.