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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.

pdf_icon New Patient Information

This document collects the patients name and contact information.

pdf_icon Consent to Treat

Patients consent to have Countryside Medical provide whatever treatment deemed necessary to their patients.

pdf_icon Financial Policy

This form will advise you about the Insurance and our Financial Policy requirements.

pdf_icon 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.

pdf_icon 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.

pdf_icon Patient History Form

This form collects all the medical history, social history and family history about our patients.

pdf_icon Health Maintenance Information

Patients will list all their surgical procedures, medications and other miscellaneous medical information to help better inform Countryside Medical as their medical provider.

pdf_icon·Advanced Directives

Florida Status requires that we provide our patients with information concerning their rights to a LIVING WILL and/or advance directive.