Forms

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Membership Agreement
This is the contract that you will be agreeing to if you decide to join this office.
2019 Membership Agreement_with ExhibitA:
Microsoft Word Document 51.2 KB

 

 

 

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Hearthside Health History Form- Please feel free to print and fill out, however we will review all of this at your first visit.
Hearthside_new_patient_history_form_upda
Microsoft Word Document 470.5 KB

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Privacy Notice- You do not need to print. When you sign up it will ask that you have reviewed this. Please review the document and click yes during registration.
Hearthside Notice of Privacy.docx
Microsoft Word Document 42.5 KB

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Hearthside Record Release Authorization
This is a release of information to receive previous records, or disclose records to another practice. If you haven't already done so, please submit a release of records to your previous provider so that we may obtain your medical records for review.
1pg 9-13-2018Hearthside Release of Recor
Microsoft Word Document 132.5 KB
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Hearthside Record Release Authorization, PDF form
This is a release of information to receive previous records, or disclose records to another practice.
Direct Primary Care Membership Agreement
Adobe Acrobat Document 207.7 KB