HIPAA Form | Riverton Medical

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Riverton Medical HIPAA Form

HIPAA Form For Riverton Medical

First Name

Last Name

List any Medical Offices you allow Riverton Medical access. (e.g. Biorestoration Medical)

List any email addresses which you allow personal medical information to be sent.

List any phone numbers which you allow personal medical information to be sent.

HIPAA Agreement: List family members, friends, medical offices, or personel which you wish to allow information to be accessed or sent.

I agree to allow my personal medical information to be stored and accessed by Riverton Medical PLLC as well as others involved with coordination of care such as pharmacies, hospitals, lab centers, and imaging centers unless otherwise prohibited by you, as the patient, in writing. Sign electronically by entering your name below.

Today's Date

Website
rivertonmedical.net

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Office
435-222-0633
5312 W Shaggy Peak Dr.
Riverton UT 84096

Contact
rivertonmedical@gmail.com
contact@rivertonmed.net

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