Whcpc.com

Patient Authorization

WEBDescription of information to be disclosed - I authorize the practice to disclose the following protected health information about me to the entity, person, or persons identified above: …

Actived: 8 days ago

URL: https://whcpc.com/wp-content/themes/whcpc/files/Release-of-Record-Authorization-2019.pdf

TO OUR OBSTETRICAL PATIENTS

WEB4199 Gateway Blvd. Suite 2300 Newburgh, IN 47630 Phone 812.858.4610 Fax 812.858.4611 Marcia L. Cave, M.D. Kimberly F. Foster, M.D. Marshall G. Howell III, M.D.

Category: Health Go Health

4199 Gateway Blvd. Newburgh, IN 47630 www.whcpc

WEB4199 Gateway Blvd. Newburgh, IN 47630 www.whcpc.com Suite 2300 Marcia L. Cave, M.D Kimberly F. Foster, M.D. Marshall G. Howell III, M.D. Dawn L. Kirkwood, M.D.

Category: Health Go Health

ADVANCE BENEFICIARY NOTICE OF N (ABN) (D) below, you …

WEBNOTE: If Medicare doesn’t pay for (D) Item(s) and Service(s) Item(s) and Services Item(s) and Services Item(s) and Services Item(s) and Services Item(s) and Services below, you …

Category: Health Go Health

PATIENT UNDER 18 AND NOT EMANCIPATED

WEBTitle: Microsoft Word - PATIENT UNDER 18 AND NOT EMANCIPATED.docx Created Date: 8/23/2019 2:28:26 PM

Category: Health Go Health

Doctor: PLEASE PRINT

WEBPATIENT’S AUTHORIZATION TO RELEASE MEDICAL INFORMATION AND CLAIM PAYMENT AUTHORIZATION. HEREBY AUTHORIZE THE ABOVE PHYSICIAN(S) TO …

Category: Medical Go Health

Doctor: PLEASE PRINT

WEBdate: _____ please print patient’s name marital status date of birth age social security no. doctor: patient information/yearly update

Category: Health Go Health

TO OUR OBSTETRICAL PATIENTS

WEB4199 Gateway Blvd. Suite 2300 Newburgh, IN 47630 Phone 812.858.4610 Fax 812.858.4611 Marcia L. Cave, M.D. Kimberly F. Foster, M.D. Marshall G. Howell III, M.D.

Category: Health Go Health

PHYSICIAN FINANCIAL INTEREST DISCLOSURE

WEB4199 Gateway Blvd. Suite 2300 Newburgh, IN 47630 Phone 812.858.4610 Fax 812.858.4611 Marcia L. Cave, M.D. Kimberly F. Foster, M.D. Marshall G. Howell III, M.D.

Category: Health Go Health

Advance Beneficiary Notice of Non-coverage rev072623

WEBA. Notifier: B. Patient Name: C. Identification Number: Advance Beneficiary Notice of Non-coverage (ABN) NOTE: If Medicare doesn’t pay for D. below, you may have to pay. …

Category: Health Go Health

Women s Health Care, P.C. Limited Patient Authorization for …

WEBWomen’s Health Care, P.C. Limited Patient Authorization for Disclosure of Protected Health Information Please print all information. Form must be signed and dated.

Category: Health Go Health

PHYSICIAN FINANCIAL INTEREST DISCLOSURE rev072623

WEBPHYSICIAN FINANCIAL INTEREST DISCLOSURE In order to allow you to make a fully informed decision about your health care, the physicians of Women’s Health

Category: Health Go Health