New Patient Forms

Authorization for Release and Disclosure of PHI (Providers and Entities)

Authorization for Release and Disclosure of PHI (English)

Authorization for Release and Disclosure of PHI (Spanish)

Authorization for Release and Disclosure of PHI (Creole)

Authorization to Disclose and Retrieve Information To/From HIE (Florida, Missouri, and Nevada Only)

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)

General Consent Form

General Consent Form (Creole)

Telehealth Services Information

Telehealth Services Information (English)

Provider History Form

Provider History Form (English)

Center Privacy Notice

Center Privacy Notice (English)

Patient Demographic Form

Patient Demographic Form (English)