Administrative Forms & Releases

Medical Record Release
Please complete the form and fax or mail to the Medical Record Department listed on the form.

Consent To Treat Form
This form can be downloaded and completed prior to your initial visit with your physician.

Download Physician Forms

Download Patient History forms for a particular physician:

HIPAA Forms

Privacy Notice (English)

This Privacy Notice is being provided to you as a requirement by Federal law, The Health Insurance Portability and Accountability Act (HIPAA), effective April 14, 2003.

This privacy notice describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law.

Summary Privacy Notice (English)

This Privacy Notice is being provided to you as a requirement by Federal law, The Health Insurance Portability and Accountability Act (HIPAA), effective April 14, 2003.

This privacy notice describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations and for other purposes that are permitted or required by law.

Privacy Notice Acknowledgement with Use or Disclosure Authorization (English)

This form tells Resurgens Orthopaedics that you have received the HIPAA privacy notice. The patient or patient representative must sign this notice.

This is an authorization form that tells Resurgens Orthopaedics who they may disclose Protected Health Information (PHI) to. The patient or patient representative must complete and sign this notice.

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