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  • Murphy Medical Associates Patient Intake Form

  • COVID-CARE BY TRAINED CLINICIANS

    A primary mission of Murphy Medical Associates is to identify positive patients and reduce the spread of COVID-19. We are a medical practice comprised of trained physicians, physician assistants and nurses. All testing is performed by trained clinicians who examine and evaluate each patient for symptoms of COVID-19, even those patients who attest to being asymptomatic, and potential exposure to COVID.

    After a patient appears for a COVID-19 test, it is our general practice to follow up with each patient to check on the patient's symptoms and conditions and to determine if further medical intervention is needed.

    If a patient tests positive for COVID-19, a member of our team will spend time with the patient describing next steps and recommend personalized treatment based on a number of factors, including the patient's pre-existing conditions.

    Even if a patient tests negative for COVID-19, we believe that follow up and care is the best and appropriate medical practice.

    COVID TESTING OPTIONS

    We have two different types of COVID testing options available. Both use a swab test, and the swabbing experience is the same. The difference occurs in where and how the test sample is processed, the turnaround time for the test, and the amount your insurance company is billed for the test.

    COVID-ONLY TEST through one of our lab partners - Depending on your medical need, lab demand, and requested turnaround time, we use partner labs such as LabCorp to process your test. Once the sample is sent to our lab partners, we do not have any control on the turnaround time for your test results.

    BIOFIRE 2.1 - Our in-house lab offers the BioFire 2.1 Respiratory Panel which tests for 21 respiratory pathogens, including COVID, as well as other forms of Corona, multiple strains of influenza, and pneumonia. As we run this test in our lab, we will be able to closer estimate a return time for your results.

    We also offer Bloodwork for COVID Antibodies.

    Bloodwork for COVID Antibodies - We can perform only-COVID antibody testing but recommend that COVID-positive patients discuss our comprehensive blood pane.

    MMA Comprehensive Blood Testing - Our comprehensive blood testing to identify COVID-19 antibodies as well as checking certain protein levels, vitamin levels, hormone levels, and other  key indicators.  This comprehensive test helps inform our team how the virus has potentially affected vital organs and systems, and helps determine a course of treatment for those who have been infected with COVID-19.

    NO COST TO PATIENTS

    For the COVID-only tests we send to our lab partners, we may bill your insurance company between approximately $200 and $600.

    For the BioFire panel tests for 21 respiratory pathogens, including COVID-19, we may bill your insurance up to approximately $1,800 for running this panel.

    For COVID Antibodies bloodwork (depending on your symptoms and medical history), we may bill your insurance between approximately $150 to $2,300.

    For telemedicine follow-up (depending on your symptoms and medical conditions), we may bill your insurance between approximately $200 to $480.

    You will not be billed for any of these costs regardless of which lab is used to process your test.

    Both federal and state laws have mandated insurance companies to pay for COVID Testing and treatment at 100% of the insurances’ contracted rate. Murphy Medical will bill your insurance company for testing and our services.

    In medical billing, insurance companies reimburses medical providers for the testing at a rate the insurance company determines, not the price a medical provider bills.

    You may get a letter from your insurance company called an Explanation of Benefits or EOB. This letter is to advise you that your insurance company has received a bill from us for the testing services provided.

    Even if the EOB says you owe a portion of the bill, under federal and state law, you do not owe anything for COVID testing. You will never receive a bill from Murphy Medical Associates for COVID testing and care.

    If you do not have insurance, we will provide you with the same standard of care and treatment. We will not turn you away, and we will never seek reimbursement from you for the medical services and care provided.

  • Please select your prefered site below or the organization sending you to test. Once you submit this form, you will get an email with links for all the locations.


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  • Medical Insurance information

    Insurance can be individual, employer-sponsored, Medicare or Medicaid plan, or any other coverage that will reimburse for COVID-19 testing or treatment.
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  • Medical History information

    Please fill these questions about your health and travels to the best of your ability.
  • Have you experienced any of the following symptoms?

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  • Do you have any of the following medical conditions? 

  • Driver's License and/or Insurance Card

    There are 3 ways to send us your ids. Take a photo now using the camera on your device, upload a photo, or text a photo later.
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  • CONSENT TO TREAT

  • SACRED HEART GREENWICH STUDENTS

    AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

    I authorize Murphy Medical Associates to disclose and release complete and legible copies of my child’s COVID-19 RT-PCR test results to Heather Elken BSN at Sacred Heart Greenwich if my child is a student at Sacred Heart.

    I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

    I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

    Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

    I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

    I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

    I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

    A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

    This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

  • Prosperity Counseling, LLC/Prosperity Housing Inc.

    AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

     
    I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to, Karen Tyson, LADC, of Prosperity Counseling, LLC.

    I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

    I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

    Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

    I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

    I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

    I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

    A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

    This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

  • SACRED HEART GREENWICH EMPLOYEES

    AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

     
    I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Sacred Heart Greenwich, Director of Human Resources.

    I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

    I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

    Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

    I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

    I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

    I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

    A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

    This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

  • Parents’ Foundation for Transitional Living - EMPLOYEES

    AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

     
    I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Executive Director, Jennifer E. Fournier, JD, Parents’ Foundation for Transitional Living.

    I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

    I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

    Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

    I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

    I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

    I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

    A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

    This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

  • Parents’ Foundation for Transitional Living - RESIDENTS

    AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

     
    I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Executive Director, Jennifer E. Fournier, JD, Parents’ Foundation for Transitional Living.

    I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

    I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

    Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

    I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

    I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

    I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

    A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

    This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

  • WEST HAVEN FIRE DEPARTMENT

    AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

     
    I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the West Haven Fire Department.

    I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

    I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

    Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

    I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

    I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

    I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

    A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

    This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

  • WEST HAVEN POLICE DEPARTMENT

    AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

     
    I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the West Haven Police Department.

    I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

    I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

    Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

    I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

    I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

    I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

    A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

    This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

  • STAMFORD FIRE DEPARTMENT

    AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

     
    I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Stamford Fire Chief.

    I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

    I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

    Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

    I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

    I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

    I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

    A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

    This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

  • STAMFORD POLICE DEPARTMENT

    AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

     
    I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Stamford Police Chief.

    I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

    I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

    Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

    I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

    I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

    I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

    A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

    This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

  • STAMFORD POLICE DEPARTMENT

    AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

     
    I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Stamford Police Chief.

    I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

    I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

    Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

    I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

    I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

    I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

    A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

    This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

  • STRATFORD FIRE DEPARTMENT

    AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

     
    I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Stratford Fire Chief.

    I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

    I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

    Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

    I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

    I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

    I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

    A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

    This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

  • STRATFORD POLICE DEPARTMENT

    AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

     
    I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Stratford Police Chief.

    I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

    I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

    Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

    I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

    I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

    I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

    A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

    This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

  • DARIEN POLICE DEPARTMENT

    AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION 

     
    I authorize Murphy Medical Associates to disclose and release complete and legible copies of my COVID-19 RT-PCR test results to the Darien Police Chief.

    I understand that I have the right to restrict the information that may be provided by signing this authorization to the extent provided by law.

    I understand the purpose of this request is to determine my current medical status and/or return-to-work/enter-the-school capability.

    Right to revoke: I understand I have the right to revoke this authorization at any time by notifying Murphy Medical Associates, I understand that the revocation is only effective after it is received and logged by Murphy Medical Associates and that any use or disclosure made prior to the revocation under this authorization will not be affected by the revocation.

    I understand that after this information is disclosed, the recipient may continue to use it pursuant to my prior authorization, regardless of my subsequent revocation of this authorization. I further understand that different protections may be available pursuant to state and federal law.

    I understand that information to be released pursuant to a pandemic may also be released to The Department of Health in the town I reside.

    I hereby expressly waive any regulations and/or rules of ethics that might otherwise prevent any hospital, health care provider or other person who has treated me or examined me in a professional capacity from releasing such records.

    A digital or other copy of this Release, which contains my signature, shall be considered as effective and valid as the original, and shall be honored by those to whom it is sent or provided for a period of six (6) months from the date it was signed.

    This Release does not authorize any personal or telephonic conferences or correspondence directly between any health care provider and a representative of my employer, its attorney or insurance carrier to discuss my case and is solely for the release of medical documentation as set forth herein. Brief communication for the limited purpose of obtaining medical records is permitted.

  • CONSENT TO TREAT

    I hereby consent to evaluation, diagnostic procedures, testing, and treatment as directed my physician or his/her designee.

    I understand that I may request and receive information on the specific affiliation(s) of any particular healthcare provider I encounter during my care.

    I understand that this Consent to Treat will be valid for each visit I make to Murphy Medical until revoked by me in writing.

    By registering for a Covid-19 test and/or a Covid-19 antibody test with Murphy Medical Associates, I hereby consent to evaluation, diagnostic procedures, testing, and treatment recommended and directed by Murphy Medical Associates. 

    Covid-19 viral RT-PCR Test

    I understand that Murphy Medical Associates, based on my registration information, symptoms at the time of testing, medical history, and other factors, may test for SARS-COV-2 (the pathogen that causes Covid-19) together with 21 additional respiratory pathogens that can either co-exist with Covid-19 or have similar indications and symptoms of Covid-19. 

    By registering for a Covid-19 viral RT-PCR Test, I consent to Murphy Medical Associates' potential use of a multi-respiratory panel. 

    Covid-19 Antibody Test

    I also understand that Murphy Medical Associates, in testing for Covid-19 antibodies, will run a blood work panel that tests for indicators beyond just Covid-19 antibodies.  I understand that Murphy Medical Associates does not test for just Covid-19 antibodies.  By registering for a Covid-19 antibody test, I consent to Murphy Medical Associates blood work panel.  

    Murphy Medical Associates encourages all patients who have any questions or concerns to speak with a member of the Murphy Medical Associates Team, either before, during or after the time of testing.

    By signing below and registering for a Covid-19 test and/or a Covid-19 antibody test with Murphy Medical Associates, I consent to the disclosure of my test results to public health authorities as requested, recommended and/or required by federal and state law. 

    I understand that this Consent to Treat will be valid for each visit I make to Murphy Medical Associates until revoked by me in writing.

    I hereby assign, transfer and set over to DMSOG/MMA sufficient monies and/or benefits to which I may be entitled from governmental agencies, insurance carriers, or others who are financially liable for my medical care to cover the costs of such care and treatment rendered to myself or my dependent(s) by DMSOG/MMA.  I further assign to DMSOG/MMA my right to commence a lawsuit under the Employee Retirement Income Security Act of 1974 (“ERISA”) or other applicable state or federal law to recover such monies and/or benefits to which I may be entitled and which I assign herein, and to pursue any other remedies, whether legal or equitable in nature, that are available under ERISA or other applicable state or federal law. This assignment includes, but is not limited to, the right to seek the equitable reformation of my health plan so that it complies with controlling provisions of federal or state law.

    I further assign to DMSOG/MMA my right to commence a lawsuit under the Employee Retirement Income Security Act of 1974 (“ERISA”) or other applicable federal or state law to recover such monies and/or benefits to which I may be entitled and which I assign herein, and to pursue any other remedies, whether legal or equitable in nature, that are available under ERISA or other applicable federal or state law. This assignment includes, but is not limited to, the right to seek the equitable reformation of my health plan so that it complies with controlling provisions of federal or state law.

  • CONSENT TO OBTAIN EXTERNAL PRESCRIPTION HISTORY/E-PRESCRIBING CONSENT FORM


    ePrescribing is defined as a physician’s ability to electronically send an understandable prescription directly to a pharmacy from the point of care. Congress has determined that the ability to electronically send prescriptions is an important element in improving the quality of patient care. ePrescribing greatly reduces medication errors and enhances patient safety.

    By authorizing MMA Murphy Medical Associates., PC and its Affiliated Providers, you allow us to view your external prescription history via the RxHub service. This will provide the physician with information about medications the patient is already taking to minimize the number of adverse drug events.

    I understand that prescription history from multiple other unaffiliated medical providers, insurance companies, and pharmacy benefit managers may be viewable by my provider and staff here, and it may include prescriptions back in time for several years.

    By signing this consent form you are agreeing that MMA Murphy Medical Associates., PC and its Affiliated Providers can request and use your prescription medication history from other healthcare providers and/or third party pharmacy benefit payers for treatment purposes.

    My signature certifies that I read and understood the scope of my consent and that I authorize the access.

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