NOW OPEN!!
I hereby authorize Tristate BANP Wellness & Vitality to disclose and verify me as a patient to any law enforcement agency, my Physican(S), Child Protective Services or any state approved Kentucky dispensary. This is valid during the period for which the recommendation has been issued. This consent is subject to written revocation only, at any time expect to the extent that action has already been taken based on this consent.
I give my permission for my medical records and file to be reviewed by another physician working with Tristate BANP Wellness & Vitality.
I understand that this might happen if the original doctor that evaluated me needs a secondary opinion, is not available, off premise, has moved or terminated His/Her practice. I will ask the doctor all questions regarding my treatment before the completion of my appointment.
