Forms For Patients

The following forms may be required for those enrolling as a new patient, or for existing patients to update information or transfer care.

To complete the PDF forms, you can either print directly or download and save the PDF to your computer..

New Patient Packet Contents:

New Patient Packet (Full packet)

Formulário de Cadastro de Pacientes (em português)

Formulario de registro de pacientes (en español)

Pakè pou Nouvo Paysan (An kreyòl ayisyen)

Annual Health Forms:

Patient Registration Form

Annual Health History Questionnaire

Treatment, Payment and Data Agreement  ( en español | em português)

Patient Representative Form:

Patient Representative Form

Pediatric Consent By Proxy:

Pediatric Consent By Proxy Form

Medical Records Forms:

Authorization for Request of Protected Health Information (for requesting records from outside provider)

Authorization for Release of Protected Health Information (for releasing records to outside provider or individual)

Autorização para Divulgação de Informações de Saúde Protegidas (para liberação de registros a profissionais externos ou indivíduos) em português

Autorización para la divulgación de información de salud protegida (para la divulgación de registros a un proveedor externo o a un particular) en español

Fòmilè Otorizasyon pou Divilgasyon Enfòmasyon Sante Pwoteje (pou divilge dosye bay yon founisè oswa yon moun ekstèn) an kreyòl Ayisyen

Request for Amendment in Medical Record

OCHS Notices:

Notice of Privacy Practices

Aviso de Práticas de Privacidade (em português)

Aviso de prácticas de privacidad (en español)

Avi sou Pratik Konfidansyalite (an kreyòl Ayisyen)

Patient Rights & Responsibilities

Completed forms may be faxed to (508) 487-6298

Please note: If you email a form(s) to Outer Cape Health Services, it will not be encrypted, and therefore not secure. If you have any questions you may contact the Compliance Department at (508) 905-2800.