HMG Consent Form Consent Form HANSA MEDICAL GROUPE FULL CONSENTMy signature below will be applied to all consent pages in this packet except for the Advanced Beneficiary Notice or ABN. You may be asked to sign the ABN in the future based on specific non-payment related circumstances. By signing below, I am consenting to have read through and understand all aspects of the Hansa Medical Groupe consent packet and the separate practice packet. I understand and agree to all parts of the Hansa Medical Groupe consent packet and responsibilities as a patient, for any primary care medical service, back-up physician medical services, any specialty care, Chronic Care Mgt, Remote Patient Monitoring, Principal Care Management Service, and/or any tele-health services provided by Hansa Medical Groupe. This includes the Credit Card Authorization, unless specified otherwise.Service Type (Select All That Apply)(Required) Primary PCP Secondary PCP Patient Name(Required) First Last Date of Birth(Required)Building Name(Required)APT #Resident Cell NumberBuilding Phone NumberPOA NamePOA PhonePOA EMAIL Relationship to PatientDigital Signature(Required)This field is hidden when viewing the formSignatureDate(Required)NameThis field is for validation purposes and should be left unchanged.
