Family Medicine at Greenhill Patient Consent Form

l, the undersigned, hereby consent to the following treatment:

• Administration and performance of all treatments
• Administration of any needed anesthetics
• Performance of such procedures as may be deemed necessary or advisable in the treatment of this patient
• Use of prescribed medication
• Performance of diagnostic procedures/tests and cultures
• Performance of other medically accepted laboratory tests that may be considered medically necessary or advisable based on the judgment of the attending physician or their assigned designees

I fully understand that this is given in advance of any specific diagnosis or treatment.

I intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing.

I the undersigned authorized FAMILY MEDICINE AT GREENHILL to use and disclose my information for the purposes of treatment, payment, and healthcare operations as described in the Notice of Privacy Practices.

A photocopy of this consent shall be considered as valid as the original.

MEDICARE PATIENTS: I authorize to release medical information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable for services to FAMILY MEDICINE AT GREENHILL.

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.