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 to Release or Disclose PHI FROM CenterWell ACE

Authorization to Release or Disclose PHI FROM CenterWell ACE (English)

Authorization to Release or Disclose PHI FROM CenterWell ACE (Spanish)

Authorization to Release or Disclose PHI FROM CenterWell ACE (Creole)

Authorization to Release or Disclose PHI TO CenterWell ACE

Authorization to Release or Disclose PHI TO CenterWell ACE (English)

Authorization to Release or Disclose PHI TO CenterWell ACE (Spanish)

Authorization to Release or Disclose PHI TO CenterWell ACE (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

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)

Missouri

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)

Nevada

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)