Wiregrass Clinic, LLC

Wiregrass Clinic, LLC

d/b/a

Dothan Surgical Services, Dothan Neuroscience Center, Dothan Internal Medicine, Metabolic and Weight Loss Surgery, Community Family Medicine, Hometown Medicine,

HealthFirst Family Medicine, Ozark Primary Care, Dothan West Family Medicine

HIPPA ACCESS FORM FOR PROTECTED HEALTH INFORMATION

I understand that it is policy of Wiregrass Clinic, LLC to restrict access to my Protected Health Information. I understand that my medical records will be accessed by the caregiver(s) providing health services, and my insurance company for payment of my claim(s). I understand that the following person/people listed will have access to my Private Health Care Information.

Patient Name: ________________________________________________________________ Patient DOB: _________________________________________________________________

Name(s)

Relationship

Phone Number

Patient Signature: ______________________________________ Witness Signature: ____________________________________

Date: ____________ Date: ____________

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