Andrew Lee
 
 
 DocuSign Envelope ID: 2EBB7621-EDFE-47BB- 
 C6C3A2DDDA86 
 ASSOCIATES MD 
 MEDICAL GROUP 
 ASSOCIATESMD MEDICAL GROUP 
 PATIENT CONSENT AND AUTHORIZATION 
 Andrew Lee 
 I, 
 FURTHER ACKNOWLEDGE THAT IN THE EVENT ASSOCIATESMD MEDICAL GROUP IS FORCED TO RETAIN THE 
 SERVICES OF A COLLECTION AGENCY AND/OR ATTORNEY; I WILL BE RESPONSIBLE FOR THE COLLECTION AND/OR LEGAL FEES. I HEREBY 
 AUTHORIZE THE DOCTOR TO RELEASE MEDICAL INFORMATION TO MY INSURANCE COMPANY TO SECURE PAYMENT OF BENEFIT. I ALSO 
 AUTHORIZE THE USE OF MY SIGNATURE ON ALL INSURANCE SUBMISSIONS AND AS AUTHORIZATION FOR PAYMENT TO BE SENT TO 
 ASSOCIATESMD MEDICAL GROUP AT 4780 SW 64th Ave Davie, FL 33314. 
 Consent to Contact. 1 hereby expressly consent to being contacted by mobile phone or mobile text messaging for the purpose of receiving 
 Information or advice about my health care, about any services officered, changes in policies, procedures, or office hours, or any other purpose 
 as determined by AssociatesMD Medical Group. Data messaging charges may apply. 
 Receipt of Notice of Privacy Practices. 
 Andrew Lee 
 I, 
 have received a copy of AssociatesMD Medical Group's Notice of Privacy Practices. 
 The physicians and staff of AssociatesMD Medical Group have my permission to speak to the following family members/friends in reference to 
 my medical care: 
 Name: 
 Andrew Lee 
 Relationship to Patient Son 
 Name: 
 John Arthur Romney 
 Relationship to Patient Best Friend 
 Name: 
 Nelson A oti 
 Relationship to Patient Best friend 
 The Physicians and staff at AssociatesMD Medical Group have my permission to leave a message on my answering machine. 
 Yes 
 No, and/or call at my place of work: 
 Yes 
 No 
 DocuSigned by: 
 Phile 
 September 28, 2022 
 Signature of responsible party 
 Date
