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PATIENT FORMS

General Consent For Treatment

Authorization for treatment, the use and release of information, and privacy policies.

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Health History Questionnaire

Your answers to the following questions will help us understand your medical history. Please fill out as much information as possible. If you cannot answer a question or feel uncomfortable answering a question, please leave them blank. Thank you for your help.

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Confidential Communications Form

Authorize others who may contact MDRI/Greenwich Bay Medicine on your behalf to obtain Protected Health Information (PHI) and to communicate with our practice regarding the patient listed.

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Consent for Disclosure of Confidential Health Information FROM MDRI

Authorize the release of PHI from MDRI to a third party.

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Consent for Disclosure of Confidential Health Information TO MDRI

Authorize the release of PHI from a third party to MDRI.

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Greenwich Bay Medicine

1407 S County Trl Suite 431
East Greenwich, RI 02818

401.398.0288
Contact Page
Mon-Fri – 8am – 5pm
Saturday – Closed
Sunday – Closed

Blackstone Valley Medicine

2 Wake Robin Rd Suite 205
Second floor
Lincoln, RI 02865

401.638.6374
Contact Page
Mon-Fri – 8am – 5pm
Saturday – Closed
Sunday – Closed