Existing Patient Forms

Authorization to Use or Disclose Protected Healthcare Information

AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION is a form you sign directing Dr. Cordoba or his staff to share your Protected Health Information with other health care providers.

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Medicare Opt-Out Form

NOTICE OF MEDICARE EXCLUSION is a form you sign acknowledging that you have read Dr. Cordoba’s policy of opting out of Medicare. Please read this carefully. Any questions should be directed to Dr. Cordoba.

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Notice of Privacy Practices – HC Provider

NOTICE OF PRIVACY PRACTICES provides the patient with critical information on their rights under the HIPAA. This document describes patient rights, choices, our uses and disclosures of your health information, and our responsibilities to you. Please review this form carefully and contact Dr. Cordoba for any questions you may have.

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Telehealth Informed Consent

TELEHEALTH INFORMED CONSENT explains the telehealth/ telemedicine provision of medical and mental health information provided by any means other than a face-to-face visit. Please read this form carefully as the terms telemedicine and telehealth are now frequently in the media. This is a form with two parts that you would sign acknowledging:

  1. your agreement for electronic communication with Dr. Cordoba or his staff.
  2. that you have read and understand the Optional National Emergency Crisis Language. Any questions should be directed to Dr. Cordoba.
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General Office Policies

GENERAL OFFICE POLICIES will provide you with an overview of information, procedures, and policies that help to guide Dr. Cordoba’s practice. Please read this acknowledging that you have done so and sign.

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