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Input Form:Deal with this potential dealer,buyer,seller,supplier,manufacturer,exporter,importer
(Any information to deal,buy, sell, quote for products or service)
Medical Records Sent To: Family Care Southwest Sent To _____ Medical Records Requested From: Family Care Southwest I authorize the release of the information specified below to the office listed above I specifically authorize the release of information regarding the following condition(s): (Please initial) _____ Drug abuse, if any _____ Substance Abuse, if any
CORHIO Health Information Exchange (HIE) Opt-Out Request Form (HIE) Opt-In Request Form that can be obtained from my health care provider A separate form must be filled out for each family member requesting to opt out Facility: Family Care Southwest P C
HIPAA Consent - Family Care Southwest, P. C. With My Consent, Family Care Southwest P C (FCSW), may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO)
NOTICE OF PRIVACY PRACTICES FAMILY CARE SOUTHWEST P. C. Family Care Southwest is commitment to protecting your information and encourage you, the patient, to contact practice staff first should any issue or question arise Our goal is to
Our Mission - portal. familycaresw. com At Family Care Southwest we strive to give our patients the best possible care in a timely manner We have the best health care system in the world, and we are committed in delivering this care efficiently and compassionately We believe the patient doctor relationship works best when it is a partnership We will work closely with you to manage
Declining to Share Personal Health Information Please sign this form if you do NOT want Medicare to share with Family Care Southwest P C your personal health information related to care you have received from other doctors or healthcare providers
Name Date of Birth - portal. familycaresw. com Family History- Indicate if any of these relate to any of your direct family members Social History Eye Exam Routine Bloodwork Advanced Care Planning Other Doctors you see Name _____ Date of Birth _____ Title: new patient form Created Date: 12 12 2021 10:02:52 PM