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Form 1 - Adult Medical Form:   X Word Fillable Format    X PDF Nonfillable
Form 2 - Insurance and Payment Consent
Form 3 - Acknowledgement of Receipt of Privacy Policy
Form 4 - Consent for Use and Disclosure and Patient Desired Communication
Form 5 - Request Health Information to be released to PHA-Adult Medicine
Form 6 - Authorization to Routine Treatment by PHA-Adult Medicine
Form 7 - Release of History Containing HIV, Drugs, Psychiatric information
Form 8 - Request PHA to Release Medical Information to Third Party
Forms
 to view these forms.
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PRIVACY POLICY CLICK HERE
New Patients - Please download, complete Forms 1-6 and bring with you to your first visit: Form 1 Word Fillable Format can be filled online then printed.
Office Forms

Philadelphia Health Associates-Adult Medicine, PC

1740 South Street, Suite 300
Philadelphia, PA 19146
TEL: 215-732-0876
www.phaadultmedicine.com