Forms

MGA New Patient Paperwork.pdf -All new patients must fill out the New Patient Paperwork before being seen. Patients 17 and under will need to have these forms filled out by a parent or guardian.

Minor Consent to Treat.pdf -Complete this form to authorize your minor child (age 17 and under) to be seen with another adult present or by his/her self. This form must be completed in the presence of a MGA employee unless it is notarized.

MSBSD Sports Physical Form.pdf -Complete this form if your minor child is being seen for a sports physical.

 

MEDICAL RECORDS

MGA Release of Information.pdf -Once received, your request will be processed and fulfilled within 5-7 working days. The records can be mailed, faxed, or picked up from the clinic; please mark your preference on the form.
*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.

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 MGA clinic, your records may be provided to you on a one time basis at no cost.