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These forms require ADOBE
ACROBAT READER which is a free download. If you do not have ADOBE ACROBAT
READER click
here
Patient
Information Form
This form is
required for first time patients or any changes to returning patients
information. It is confidential and required for patient information processing.
Eligibility
waiver Form
This
form is required for first time patients or any changes to returning patients
information. It is confidential and required for patient information processing.
Frederal
Truth in Lending Statement Form
This
form is required for cash paying patients for all visits.
Records
Release Authorization Form
This form is required for patients who wish to have their previous medical
records transfered from another medical facility/office to Family Physicians
of Southern Nevada.
Records
Disclosure Authorization Form
This form is required for patients who wish to have their current medical
records transfered from Family Physicians of Southern Nevada to another
medical facility/office.
ACKNOWLEDGEMENT
OF RECEIPT OF NOTICE
OF PRIVACY PRACTICES
This form is required by all first time patients. This form is to be signed
in the Family Physicians of Southern Nevada Office. It is used to verify
that all patients have read and understand the Notice of Privacy Practices
Document.
Notice
of Privacy Practices Document
This Document defines the privacy practice agreement between the patient
and Family Physicians of Southern Nevada under the State Laws of Nevada.
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