Patient Request for PHI

Patient Request for PHI (English)

Patient Request for PHI (Spanish)

Patient Request for PHI (Creole)

New Patient Form

New Patient Form (English) 

New Patient Form (Spanish)

New Patient Form (Creole)

General Consent Form

General Consent Form (English)

General Consent Form (Spanish)

General Consent Form (Creole)

Authorization for Release and Disclosure of PHI (Person or Organization)

Authorization for Release and Disclosure of PHI (Person or Organization) Form (English)

Authorization for Release and Disclosure of PHI (Person or Organization) Form (Spanish)

Authorization for Release and Disclosure of PHI (Person or Organization) Form (Creole)

Authorization for Release and Disclosure of PHI (Providers and Entities)

Authorization for Release and Disclosure of PHI (Providers and Entities) (English)

Authorization for Release and Disclosure of PHI (Providers and Entities) (Spanish)

Authorization for Release and Disclosure of PHI (Providers and Entities)(Creole)

Notice of Privacy Practices

Notice of Privacy Practices (English)

Notice of Privacy Practices (Spanish)

Center Privacy Notice

Center Privacy Notice (English)

Center Privacy Notice (Spanish)

Center Privacy Notice (Creole)

Provider History Form

Provider History Form (English)

Authorization to Disclose and Retrieve Information To/From HIE (Florida, Missouri, and Nevada Only)

Authorization to Disclose and Retrieve Information To/From HIE (English)

Authorization to Disclose and Retrieve Information To/From HIE (Spanish)

Authorization to Disclose and Retrieve Information To/From HIE (Creole)