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Tomeka Robert M.D. P.C


  Last name

  Mid name

  First name

Patient Consent information

Any physician, staff, employee or representative of Tomeka Roberts, M.D.,P.C. has my permission to discuss my account and medical conditions which may include symptoms, treatments, diagnosis, test results, medications or any other type of protected health information with the following persons in order to facilitate and coordinate my care, treatment and payment:
Name Relationship Phone Number
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* I understand that authoring the release of any information to the above individuals(s) is voluntary and does not affect any access to treatment. I can refuse to sign this form at any time. I can revoke it by writing to Tomeka Roberts, M.D., P.C. or by completing a new form at any time. This authorization will remain in effect until I change or revoke it. I understand that if this information is shared with the above individuals it may be subject to redisclosure by the individuals(s).
*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)