• Medical Information Release

    Agreement to do business with Dr. Daniel Farkas, Back to Health Natural Solutions LLC.
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  • Release of Medical Information

  • Permission to get records

  • I, *, with a date of birth, *, give my permission for*   to give my medical records (as described on p. 2) to Dr. Daniel Farkas so that he can better understand my condition and help me.

  • Permission to get sensitive information

  • By putting my initials by each item below, I understand that I give permission for records to be sent that may contain information about:

  • * my mental health

  • * transmittable disease I may have like HIV/AIDs,

  • * genetic records, and/or

  • * drugs and alcohol records.

  • I understand that:

    • I do not have to give my permission to share these records. 
    • If I want to take away the permission for my doctor to get these records, I need to talk to my doctor or a staff person and sign a paper. 
    • This form is only good for 3 months from the date I sign it. 
  • Clear
  • Date: *

  • Clear
  • Date:

  • Relationship of Authorized Representative

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  • Should be Empty: