MGA New Patient Paperwork.doc

Minor Consent to Treat.docx -Complete this form to authorize your minor child to be seen with another adult or by his/her self. This form must be completed in the presence of an MGA employee unless it is notarized.

MSBSD Sports Physical Form.pdf -Bring this form with you to your Sports physical appointment.

MGA ROI.pdf -Complete this form to request or release medical records.

-Once received, your request will be processed and fulfilled within 5 working days. The records can be mailed, faxed, or picked up from the clinic.

Due to the high volume and time consuming nature of requests, MGA has implemented the charges below for medical records.

PAPER COPIES:                                                                                                ELECTRONIC FORMAT

1-25 pages:         FREE                                                                                     DISC:     $15.00

26-50 pages:     $20.00                                                                                  

51-75 pages:     $25.00

76-100 pages:   $30.00

100+ pages:      $40.00

Charges will not exceed $40.00 and payment will be due prior to records being released to you.

The offices of MGA will not charge a fee for processing requests for releases to medical insurance companies or for Workers’ Compensation.

If you are discharged from a clinic of MGA, your records may be provided to you on a one time basis at no cost.