Patient

Forms

DOCUMENTS & FORMS

Financial Policies

Authorization for assignment of benefits

Interpreter Services

Interpreter Services Form

Medical Record Release from ICC

Authorization for ICC to release medical records

Medical Record Release to ICC

Authorization to disclose information to ICC

New Patient

First time patient information form

Nondiscrimination

Notice of Nondiscrimination Form

Permission to be Seen

Permission for children to be seen with non-parent/guardian

Privacy Notice

Notice of Privacy Practices

Alabama High School Athletic Association Physical Form

Please complete page 1 prior to submitting physical form to our office

Standard Office Forms Translated into Spanish

 

Financial Policies - Spanish

Authorization for assignment of benefits

AUTORIZACIÓN PARA ASIGNACIÓN DE BENEFICIOS

Y

AUTORIZACIÓN PARA DIVULGAR O RECIBIR INFORMACIÓN MÉDICA

Medical Record Release from ICC - Spanish

Authorization for ICC to release medical records

Autorización para divulgar información médica protegida

Medical Record Release to ICC - Spanish

Authorization to disclose information to ICC

Autorización para divulgar información médica protegida

New Patient - Spanish

First time patient information form

Por favor escriba todos los pacientes que se encuentran actualmente en nuestra práctica.

Nondiscrimination - Spanish

Notice of Nondiscrimination Form

La discriminación es ilegal

Permission to be Seen - Spanish

Permission for children to be seen with non-parent/guardian

PERMISO PARA QUE NIÑOS SEAN VISTOS POR MEDICO CON OTRA PERSONA A PARTE DE PADRES/GUARDIAN

Privacy Notice - Spanish

Notice of Privacy Practices

AVISO DE PRÁCTICAS DE PRIVACIDAD

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INFANTS’ & CHILDREN’S CLINIC, PC

421 W College St

Florence, AL 35630

(256) 764-9522

fax (256) 764-1139

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WELL CHILD CLINIC

1605 Mockingbird Ct

Florence, AL 35630

(256) 764-9522

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