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Internal Medicine
Primary Care
Preventative Care
Providers
Christopher Brana, MD
Michelle Fishman, PA-C
Tessa Shuler, FNP-C
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Internal Medicine
Primary Care
Preventative Care
Providers
Christopher Brana, MD
Michelle Fishman, PA-C
Tessa Shuler, FNP-C
About Us
Our Team
Resources
Patient Forms
Policies Fees And Insurance
Make a Payment
Blog
Accessibility Statement
Contact
Services
Internal Medicine
Primary Care
Preventative Care
Providers
Christopher Brana, MD
Michelle Fishman, PA-C
Tessa Shuler, FNP-C
About Us
Our Team
Resources
Patient Forms
Policies Fees And Insurance
Make a Payment
Blog
Accessibility Statement
Contact
Services
Internal Medicine
Primary Care
Preventative Care
Providers
Christopher Brana, MD
Michelle Fishman, PA-C
Tessa Shuler, FNP-C
About Us
Our Team
Resources
Patient Forms
Policies Fees And Insurance
Make a Payment
Blog
Accessibility Statement
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Appointment
Services
Internal Medicine
Primary Care
Preventative Care
Providers
Christopher Brana, MD
Michelle Fishman, PA-C
Tessa Shuler, FNP-C
About Us
Our Team
Resources
Patient Forms
Policies Fees And Insurance
Make a Payment
Blog
Accessibility Statement
Contact
Services
Internal Medicine
Primary Care
Preventative Care
Providers
Christopher Brana, MD
Michelle Fishman, PA-C
Tessa Shuler, FNP-C
About Us
Our Team
Resources
Patient Forms
Policies Fees And Insurance
Make a Payment
Blog
Accessibility Statement
Contact
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Medical & Financial Release Form
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Release of Medical or Financial Information
Due to State and Federal policy relating to privacy it is necessary to have written permission to discuss any personal medical or financial information such as medication, laboratory, radiology, diagnosis and prognosis with anyone other than yourself such as husbands, wives, children, or other relatives or friends. Please list below any person(s) to whom you will allow us to release any medical or financial information. If no one is listed then we will only discuss your medical and financial information with you. Information will still be provided to other health care providers, hospitals, or your insurance companies for the purpose of authorizations or other treatment or specialty referrals. Information to any other entity will need your separate signature specifically authorizing them to access your records.
I hereby authorized you to release my medical or financial information to the following
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Name
Relationship
Name
Relationship
If you have additional names please list them on the back of this notice.
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