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REQUEST AN APPOINTMENT (OXON HILL)

REQUEST AN APPOINTMENT (COLUMBIA)

REQUEST AN APPOINTMENT (LUSBY)

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Forms

ENGLISH

PATIENT REGISTRATION
CONSENT TO TREAT
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY OF PRACTICES
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

ESPAÑOL

REGISTRO DEL PACIENTE
CONSENTIMIENTO PARA TRATAMIENTO
RECONOCIMIENTO DE RECIBO DEL AVISO DE PRIVACIDAD DE PRÁCTICAS
AUTORIZACIÓN PARA LA DIVULGACION DE REGISTROS MÉDICOS

LOCATIONS IN MARYLAND

COLUMBIA. 9710 Patuxent Woods Dr., Suit 200. Columbia, MD 21046
OPEN MONDAY TO FRIDAY 9AM - 5PM
(CLOSE SATURDAYS AND SUNDAYS)

OXON HILL. 5474 St. Barnabas Road. Oxon Hill, MD 20745
OPEN MONDAY TO FRIDAY 9AM - 5PM
(CLOSE SATURDAYS AND SUNDAYS)

LUSBY. 225 Town Aquare Drive. Lusby, MD 20657
OPEN MONDAY TO FRIDAY 9AM - 5PM
(CLOSE SATURDAY AND SUNDAYS)

CAMP SPRINGS. 4821 Allentown road. Camp Springs, MD 20748
(TELEMEDICINE APPOINTMENTS ONLY)

FOR ANY LOCATION CALL US TO MAKE AN APPOINTMENT AT 443-899-9525

fax: 833-605-7347

info@premierhealthexpress.com

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