EMPOWER FAMILY MEDICINE PATIENT AGREEMENTMedicine Patient Agreement • June 14th, 2018 • Georgia
This is an Agreement between Empower Family Medicine, L.L.C., a Georgia professional corporation, located at 209A Swanton Way Suite 101, Decatur, GA 30030, and you, (Patient, Principal). Melissa Black M.D. (Physician) serves as an agent of Empower Family Medicine (EFM). The person indicated as Principal agrees to assume financial responsibility for the Patients indicated.
