Forms to Bring In with you
| Forms | Description |
|---|---|
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Patient Registration form. This is a required form. |
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An Authorization form to authorize Dr.Canaan Harrris to release medical information necessary to process claims for the services provided. Also authorization payment of government /medical benefits to Dr. Canaan Harrris for services provided. |
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Patient History information, and Social History information |
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Patient past medical history (page 1) |
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Patient past medical history (page 2) |
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list of symptoms, functional limitations, and emotional consequences of your rhinosinusitis. We would like to know more about these problems, and how they impact your life |
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PURPOSE: This form is used to confirm that an individual has received |
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PATIENT’S RIGHT AND RESPONSIBILITIES (Page 1) |
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PATIENT’S RIGHT AND RESPONSIBILITIES (Page 2) |
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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN HAVE ACCESS TO THIS INFORMATION PLEASE REVIEW IT CAREFULLY, THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US (Page 1) |
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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN HAVE ACCESS TO THIS INFORMATION PLEASE REVIEW IT CAREFULLY, THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US (Page 2) |
