3 Care Lane, Suite 100 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your Patient Name and AMD Chart # in the designated fields. This information is crucial for identifying your medical records.
3. Fill in your Date of Birth accurately to ensure proper verification of your identity.
4. Review the Medical Release of Information section. Here, you will authorize Richard Kim Medicine to share your medical information as needed. Initial where indicated to confirm your understanding.
5. If applicable, read and sign the Medicare authorization section. Ensure you initial this part if you are a Medicare patient.
6. Complete the Compensation / No Fault Release by confirming that your visit is not related to a work injury or motor vehicle accident with your initials.
7. Acknowledge the Audio and Video Recording Policy by initialing after reading it carefully. This ensures compliance with quality and safety standards.
8. In the final section, specify who can receive your personal health information and provide your signature along with that of a witness if required.

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