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Welcome Check List |
Our check list will help assure that you bring everything needed for your first visit |
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Patient Registration Form |
Patient Demographics and insurance information |
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Patient & Family Health History Form |
This form gathers information about your family, including your parents, grandparents and siblings health history that can assist us in helping you. |
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Review of Systems Form |
A screening device to uncover potentially significant symptoms that might not otherwise apparent. These include symptoms related to the history of your present illness, other active problems which will aid in making a diagnosis |
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Financial Policy |
A statement of our payment, credit and financial policy requirements |
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Medical Records Release |
To authorize the transfer of your personal medical files and information to Dr. Faria and other healthcare providers |
NOTICE OF PRIVACY PRACTICES
Dr. Russell W. Faria and Staff respect your privacy. We understand that your personal health information is very sensitive. We will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so.
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Notice of Privacy Practices
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Privacy Notice describes how medical information about you may be used and disclosed, and how you can get access to this information. This Notice can be viewed either on-line or printed. |
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Acknowledgement Form |
Please sign and bring with you the Privacy Notice Acknowledgment form. It indicates that you have been made aware of our Privacy Practices. |