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CONSENT TO  RELEASE OF PERSONAL AND HEALTH CARE INFORMATION

To: 

Winnick Patient Advocacy LLC/ Scott J. Winnick
6214 Silverbrooke West
West Bloomfield, Michigan, U.S.A. 48322-1027
Tel:  (248) 624-9884
scott@patient-health-advocacy.com
 

Name:

Address:

City:     State/Province:

Zip/Postal:     Country:

Tel: (H):      (O):   (C):

e-mail:

Date of birth: (mm/dd/yyyy)

I, , hereby consent to Winnick Patient Advocacy (WPA),

Scott J. Winnick, and his/ its employees, contractors, consultants and other parties who require such information to assist us with establishing, maintaining and managing our relationship with you, to sharing, disclosing, and releasing any personal, health care, or other information to any party WPA/ Scott J. Winnick deem(s) appropriate, in order to assist myself, my spouse, or my family.

This information may be communicated via electronic or other means across State/ Provincial, Federal and International boundaries.

Signature

(typing your name on above line is equivalent to Signature of Client/ Guardian/ Authorized Representative and signifies your agreement to the above statement)

Date: (mm/dd/yyyy)


Witnessí typed name (equivalent to signature):

Date:   (mm/dd/yyyy)

Name:

Address:

City:     State/Prov:

Zip/Postal:  Country:

Tel:

e-mail:

Winnick Patient Advocacy LLC
6214 Silverbrooke W.
W. Bloomfield, MI 48322 USA .Tel: 248-624-9884

"From Diagnosis to Treatment on a Workable Path" tm

"Helping You With
Your Medical Care" tm

"Taking Care of You
Like Family" tm

 

 

 

 

 

 

 


 

Copyright © 2007 by Winnick Patient Advocacy LLC
 
Winnick Patient Advocacy LLC 6214 Silverbrooke West . W Bloomfield, MI 48322 USA 248-624-9884