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.

1. Patient Acknowledgement and Consent

Download the form in:

The patient agreed to the Patient Acknowledgment and Consent form

2. Authorization to Release Medical Information

Download the form in:

The patient agreed to the Authorization to Release Medical Information form

Patient Name

Date of Birth

Email Address

State

PRM Name

Greenway ID

I asked the patient their name, and they confirmed

I asked the patient their date of birth, and they confirmed

Get access to care, right in your neighborhood.