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Martin One Source

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Actived: 4 days ago

CONSENT FOR TREATMENT AND GENERAL …

Web3 of 9 CONSENT UNIVERSAL CONSENT imprint who participate in my care. I acknowledge that Carle shares its electronic medical record system with other healthcare entities

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Authorization to Release Protected Health Information

WebAuthorization to Release Protected Health Information X3864-0223 ROI Request for Imaging Today’s Date: Date needed: A.M./P.M. Return this completed form to: Carle …

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AUTHORIZATION TO RELEASE PROTECTED HEALTH …

WebAUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION 174-0619 ROI Patient Name: Date of Birth:

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INFORMED CONSENT FOR ASPIRATION AND/OR INJECTION …

WebPROCEDURE(S) I authorize to perform the following procedure(s) on me for the treatment of my current medical condition, and I voluntarily

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CARLE HEALTH AUTHORIZATION FOR RELEASE OF MEDICAL …

WebCARLE HEALTH AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION INSTRUCTIONS: PATIENT IDENTIFICATION Make sure all blanks are filled in. Failure …

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Authorization to Release Protected Health Information

WebA separate special authorization must be completed to release mental health records. • I have the right to inspect and obtain a copy of the records that are to be disclosed (CFR …

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INFORMED CONSENT FOR SURGERY AND/OR PROCEDURES …

WebI have had the opportunity to ask questions which have been answered to my satisfaction and agree to proceed. CONSENT FOR TREATMENT. Signature of Patient or Authorized …

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REQUEST FROM LAW ENFORCEMENT FOR RELEASE OF …

WebPatient’s Name (if known): _____ Date: _____ Requestor’s Name: _____ Title/ID#: _____ Agency Name: _____ Phone Number: _____

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ONGOING AUTHORIZATION FOR REQUEST/RELEASE OF …

Webongoing authorization for request/release of health information to agencies x0933-1118 roi patient name: date of birth:

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Carle Outside Referral Forms

Web808 North Country Fair Drive Champaign, IL 61821 (217) 398-8000

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Discharge/Transfer/ Referral Policy of Carle Home Care Patients

WebDischarge/Transfer/ Referral Policy of Carle Home Care Patients Carle Home Care is professionally and ethically responsible for providing care and services within its financial

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PATIENT RIGHTS & RESPONSIBILITIES

WebPATIENT RIGHTS & RESPONSIBILITIES • Refuse care by students in training. • Have all medical communication interpreted by a certified interpreter in patient’s language.

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Authorization To Release Information

WebUse this side if multiple parties are being requested to release or receive medical information. I authorize the following parties/agencies to release and/or receive (as the …

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CARLE HEALTH & AFFILIATE PRIVACY NOTICE

Webcarle health & affiliate privacy notice this notice describes how medical information about you may be used and disclosed and how you can get access to this

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INFORMED CONSENT FOR ADMINISTRATION X5385-1013 OF …

WebSignature of Patient or Authorized Person Date Time _____ _____ / _____ Signature of Witness Date Time

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Patient Instructions Laboratory Hours of Operation

WebX1864-0221 Patient Instructions Laboratory Hours of Operation Laboratory and Pathology Services Specimens collected outside the Laboratory must be returned to one of these …

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X1751 Authorized Relative Certification

WebAUTHORIZED RELATIVE CERTIFICATION. (A certified copy of the death certificate must be attached.) certify that to the best of my knowledge and belief that no executor or …

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