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Patient Forms
Here at Countryside Medical we care about relationships with all our patients. We make it a point to inform them of the overall medical and financial process that relates to them. Here is a list of documents that are required in order to facilitate patient care.
This document collects the patients name and contact information.
Patients consent to have Countryside Medical provide whatever treatment deemed necessary to their patients.
This form will advise you about the Insurance and our Financial Policy requirements.
Patient Consent for Use & Disclosure of Protected Health Information
Countryside Medical may use and disclose protected health information about our patients in order to carry out medical treatment and payment.
Authorization for Disclosure of Protected Health Information
This form will give our office permission to use and/or disclose health information about you to aide or continue treatment of your healthcare.
This form collects all the medical history, social history and family history about our patients.
Health Maintenance Information
Patients will list all there surgical procedures, their medications and other miscellaneous medical information to help better inform Countryside Medical as there medical provider.
Florida Status requires that we provide our patients with information concerning their rights to a LIVING WILL and/or advance directive.
