patient forms

Access 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.