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FORMS
and RESOURCES
To
better help us serve you, we would appreciate if you could fill out and sign
the following forms.
We have provided you with online access to the patient information forms
that all patients must complete prior to their first visit.
You will need Adobe
Reader to be able to open and print these files. Adobe Acrobat
Reader is free from Adobe Systems
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Welcome
Check List |
Our check list
will help assure that you bring everything needed for your
first visit |
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Patient Registration Form |
Patient Demographics and
insurance information |
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Patient & Family
Health History Form |
This
form gathers information about your family, including your
parents, grandparents and siblings health history that can
assist us in helping you. |
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Review of Systems Form |
A screening
device to uncover potentially significant symptoms that might not
otherwise apparent.
These include
symptoms related to the history of your present illness, other active
problems which will aid in making a diagnosis |
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Financial Policy |
A
statement of our payment, credit and financial policy requirements
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Medical Records Release
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To
authorize the transfer of your personal medical files and information to
Dr. Faria and other healthcare providers |
NOTICE OF PRIVACY PRACTICES
Dr Russell W. Faria and Staff
respect your privacy. We
understand that your personal health information is very sensitive. We
will not disclose your information to others unless you tell us to do
so, or unless the law authorizes or requires us to do so.
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Notice of
Privacy Practices |
Privacy Notice describes how medical information about you
may be used and disclosed, and how you can get access to this
information. This Notice can be viewed either on-line or
printed. |
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Acknowledgement Form |
Please sign and bring with you the
Privacy Notice Acknowledgment form. It indicates
that you have been made aware of our Privacy
Practices. |
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