Patient Forms
-
Effective Date 9-17-2013
Privacy Notice
This notice describes how medical information about you may be used and disclosed and how you can get access to this information please review it carefully.
Privacy -
9-17-2013
Revocation Of Authorization
A patient may revoke in writing a disclosure authorization to a health care provider at any time unless disclosure is required to effectuate payments for health care that has been provided or other substantial action has been taken in reliance on the authorization.
Revocation -
9-17-2013
Patient Acknowledgement
This is to acknowledge that you have been given a copy of our Notice of Privacy Practices, version effective for 9-17-2013.
Acknowledge -
9-17-2013
Consent For Release
consent to disclosure of the following protected health information about me to the following family member(s) or person(s) involved in my care or payment for my care.
Consent -
9-17-2013
Authorization for Use
Authorize the use or disclosure of your individually identifiable health information as described in the form. Understanding that this authorization is voluntary.
Authorize -
6-17-2014
New Patient Screening
The new patient screening form is to help familiarize us with your current medical status.
Screening -
6-17-2014
Medical History
Medical History is information obtained by a physician by asking specific questions, with the focus of obtaining information useful in formulating a diagnosis and providing medical care to the patient.
History -
6-17-2014
Medication History Consent
By signing this form you are giving Dayspring Family Medicine permission to access pharmacy benefits data electronically.
Medication -
6-17-2014
Authorization for Treatment of a Minor
This form will give permission for your child to be medically evaluated and treated by Dayspring Family Medicine if you the parent are not present.
Authorize