patient formsAccess patient forms and resources needed for getting started with Enliven
Patient Forms
-
Authorization for Release of Medical Information (English)
This allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
-
Authorization for Release of Medical Information (Spanish)
This allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.
-
Authorization and Consent for Treatment (English)
All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.
-
Authorization and Consent for Treatment (Spanish)
All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.
-
Informed Consent for Telehealth Services (English)
This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.
-
Informed Consent for Telehealth Services (Spanish)
This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.
-
Patient Designated Contacts (English)
Patients are encouraged to complete and return the Patient Designated Contacts Form to Enliven Health & Wellness, but it is not required.
-
Patient Designated Contacts (Spanish)
Patients are encouraged to complete and return the Patient Designated Contacts Form to Enliven Health & Wellness, but it is not required.
-
Health Information Exchange (HIE) Opt-Out (English)
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.
-
Health Information Exchange (HIE) Opt-Out (Spanish)
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
Office Policies
-
Financial Policy (English)
This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations
-
Financial Policy (Spanish)
This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations
-
Notice of Privacy Policies (English)
Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information.
-
Notice of Privacy Practices (Spanish)
Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information.
-
Language Services
Learn about the free language services available to you as a patient of this Care Center, including qualified interpreters and written information in other languages, and how to request these services or get more information if they are not provided.