Patient Forms
Last Updated on Monday, 19 November 2012 20:10
Gynecological Forms:
The Patient Information
Health History Notice Of Privacy
Notice Of Privacy Acknowledgment Form
Health Concerns
Obstetrical Forms:
The Patient Information
Health History
Genetic History
Notice Of Privacy
Notice Of Privacy Acknowledgment Form
Health Concerns
Infertility Forms:
The Patient Information
Health History
Notice Of Privacy
Notice Of Privacy Acknowledgment Form
Health Concerns
General Forms:
Notice Of Privacy
Notice Of Privacy Acknowledgment Form
Health Concerns
Record Release Authorization
Financial Policy:
Financial Policy
Obstetrical Care Fees Surgical Policy
Patient Payment Policy
Circumstances may arise that requires a patient transfer their medical care to another physician. Such reasons may include moving out of the area or a change of medical insurance that Partners in Womens Healthcare is not a participating provider. In order for the patient to obtain a copy of their healthcare information an authorization form must be accurately completed. Please, make certain the form is completed in its entirety with special attention made to authorizing the release of information regarding the four specially protected areas: substance abuse, mental health, HIV and sexual abuse. In order for this authorization to be valid the patient’s signature must be witnessed. Be aware there may be costs associated to the photocopying of the medical record. Usually it is not necessary to request the entire medical record, but only the pertinent or more recent health information (past three years). We request two weeks advance notice to prepare the medical records. Primarily for security reasons, but also to reduce costs; we request the patient pick-up their medical records from our office. Photo identification is required at the time of pick-up. If there are any questions regarding this process, please, do not hesitate to call our office.
