Important Forms
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Important Forms
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Selection | File type icon | File name | Description | Size | Revision | Time | User |
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Ċ | View Download |
Please fill out this form if you would like to have your medical information shared between myself, another specified medical provider or insurance carrier. I would request or share information only after your permission is given. | 87k | v. 3 | Oct 9, 2014, 1:52 PM | Heather Chatfield |
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Ċ | View Download |
Please fill this form out as a means of acknowledging and accepting the terms of canceling a scheduled appointment with me. | 45k | v. 3 | Apr 27, 2012, 5:18 AM | Heather Chatfield |
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Ċ | View Download |
This form re-affirms your rights concerning your personal information and our assurances to handle it properly. | 75k | v. 3 | Apr 27, 2012, 5:18 AM | Heather Chatfield |
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Ċ | View Download |
This notice describes how medical and other personal information about you may be used and disclosed. It also describes how you can get access to this information. Please review the notice carefully. | 113k | v. 3 | Oct 9, 2014, 1:53 PM | Heather Chatfield |