Ridgeviewfamily.com

Patient Resources

WebIt encompasses a wide range of health services, from preventive care to the diagnosis and treatment of acute and chronic diseases. Primary care providers develop a comprehensive understanding of their patients’ health over time, ensuring personalized care and guiding patients through the health system, including referrals to specialists if

Actived: 8 days ago

URL: https://ridgeviewfamily.com/resources/

PATIENT INFORMATION SHEET

WebMental Health ☐Yes ☐No Teeth/Gum Disease ☐Yes ☐No Other Medical Conditions: How many visits to the Emergency Room (ER) have you had in the past 12 months? 0☐ ☐ 1-2 ☐ 3+ How many overnight stays at the hospital have you had in the past 12 months?

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Authorization to Use and Disclose Protected Health Information

Webhealth information while the Authorization was in effect. • I may refuse to sign or may revoke this Authorization at any time for any reason and that such refusal or revocation will not affect the commencement, continuation, or quality of “this facility” treatment of me, enrollment in the health plan, or eligibility for benefits.

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Ridgeview Family Health Consent Form

WebFinancial Policy: As a courtesy, Ridgeview Family Health will bill most health insurance companies. I am responsible for paying all co-pays and co-insurance at the time of service. My share of the costs, including all co-payments, deductibles and co-insurances are my responsibility to pay. I understand that

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HIPAA Privacy and Release of Information Authorization

Webinformation relating to the diagnosis, treatment, claims payment, and health care services provided or to be provided to me and which identifies my name, address, social security number, Member ID number) for the purpose of helping me to resolve claims and health benefit coverage issues.

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