MyHealth LLC

14502 Greenview Dr #500 L21, Laurel, Maryland, 20708

301-728-3574

PATIENT INTAKE FORM

A Registered Caregiver is a person chosen by the patient to act as their agent in obtaining their medication at the dispensary
If yes, please provide documentation.

  • Other medical condition which is severe and for which other treatment have been ineffective:_____

PRIVACY POLICY AND PRACTICES

As a patient of MyHealth LLC:

I understand I have rights to privacy of my protected health information as defined by the Health Insurance Portability Act of 1996.

I have been made aware that upon request a copy of MyHealth LLC’s privacy policy is available to me.

MyHealth LLC has made me aware of their right to change the terms of its Notice of Privacy Practice.