Accessibility Tools

Patient Forms

Authorization for Release of Medical InformationSpanish Authorization for Release of Medical InformationAuthorization for Release of Medical Information (PDF)

Allows patients to authorize the disclosure of their health information to a designated individual, company, agency or facility.

Autorización De HIPAA Para Divulgar Información Del Paciente (PDF)

 

Preferred ContactsSpanish Preferred ContactsPatient Designated Contacts (PDF)

Patients are encouraged to complete and return the Patient Designated Contacts Form but it is not required.

Contactos designados del paciente (PDF)

 

Informed Consent for Telehealth ServicesSpanish Authorization for Release of Medical InformationInformed Consent for Telehealth Services (PDF)

This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

Consentimiento informado para servicios de telesalud (PDF)

 

Preferred ContactsSpanish NPPHealth Information Exchange (HIE) Opt-Out (PDF)

This form allows patients to opt out of sharing their PHI via the Health Information Exchange (HIE). The HIE securely shares patient information electronically among a network of healthcare providers, such as physicians, hospitals, labs and pharmacies. 

Formulario de solicitud de exclusión voluntaria de Privia HIE (PDF)