Patient forms for PRM to complete

Please read and check the box for each form then sign at the bottom. These forms will need to be completed prior to your Telehealth visit.

Patient Acknowledgement and Consent (Spanish) (Polish)

Authorization to Release Medical Information (Spanish) (Polish)

PRM to confirm with patient I asked the patient their name and they confirmedI asked the patient their Date of Birth and they confirmedThe patient agreed to the consent to care documentThe patient agreed to the request for information document

Patient name

Patient date of birth

PRM name

Greenway ID