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Patient Information
Spanish Version
Simplify the front office paperwork
These forms are designed for the patient for whom Spanish
is a first language.
This form can simplify paperwork for the front office. It
provides sections for general information and responsible party details;
suitable for adults and children. For patients with insurance, primary
and/or secondary insurance information can also be noted.
The authorization section allows for assignment of
benefits, "signature on file", general consent (Click on Informed
Consent Forms for more information), and information release. This
authorization can also be photocopied and attached to an insurance claim
form.
FORM FEATURES
- Patient information
- Responsible party
- Accepted format for adults and children
- Information for primary / secondary insurance coverage
- Same information as English version
- Identical format as English version
- Provides insurance authorization
- Provides general consent
- Facilitates data collection for Spanish speaking patients
| C-114L SP |
Patient Information
Spanish |
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$12.00/50
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To preview
Sample Form in PDF format
CLICK HERE
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