MEDICAL RELEASE TO LEAVE MESSAGE ON VOICE MAIL:

I ______________________________________GIVE CARROBORO FAMILY MEDICINE

CENTER PERMISSION TO LEAVE A VOICE MAIL ON
______________________________PHONE NUMBER.

I GIVE PERMISSION FOR MESSAGE’S TO BE LEFT CONCERNING:

PLEASE CHECK ALL THAT APPLY:

LAB /PAP RESULTS: _________________

RADIOLOGY REPORTS: _______________

APPOINTMENT’S: ______________________

PRESCRIPTION’S: ____________________

MEDICAL ADVICE: ____________________

REFERRAL’S: _______________________

IS THERE ANY INFORMATION THAT YOU DO NOT WANT LEFT ON VOICE MAIL?

______________________________________________________________________________

SIGNATURE: _________________________________________________

PRINT NAME: ___________________________________________________

DATE: _______________________________
 C ARRBORO FA MILY M E DICINE

PE RS O N A L I N F O R M A T I O N:

N A M E:_____________________________________________________

A D D R E S S:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
___________________________________________________________________________

H O M E:____________________________

W O R K:____________________________

C E L L:_____________________________

D A T E O F B I R T H _______________________________

S S N#__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

SE X: F E M A L E ____________ M A L E ____________

I N S U R A N C E:

P O L I C Y H O L D E R N A M E ______________________________

D A T E O F B I R T H ____________________________________

S S N#__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
 CARRBORO FAMILY MEDICINE CENTER, P.A.

PATIENT CONSENT FOR USE OR DISCLOSURE OF

PROTECTED HEALTH INFORMATION (PHI)

IF WE ARE UNABLE TO REACH YOU, ARE THERE ANY RELATIVES OR FRIENDS WITH
WHOM YOU AUTHORIZE OUR OFFICE TO DISCUSS YOU HEALTH INFORMATION?

YES__________ NO___________

IF YES, PLEASE LIST THEIR NAMES, RELATIONSHIP AND PHONE NUMBERS.

1) NAME: _______________________________________________________

RELATIONSHIP: ____________________________

PHONE NUMBER: _____________________________

2) NAME:__________________________________________________________

RELATIONSHIP: ______________________________________

PHONE NUMBER: ___________________________________________

THIS AUTHORIZTION IS IN EFFECT UNTIL REVOKED IN WRITING.

PRINT PATIENT NAME: __________________________________________________

PATIENT/GUARANTOR SIGNATURE: ______________________________________________

DATE: ___________________________________________
 MEDICAL APPOINTMENT CANCELLATION POLICY

Dear Patient,

Carrboro Family Medicine strives to render excellent medical care to you, your family, and all of our patients. In order to be
consistent with this philosophy, Carrboro Family Medicine uses an appointment system that sets aside time for a patient
dependent on that patients current need. When you do not show up for your appointment or notify us of your inability to keep
your appointment by phone at least 24 hours in advance, the time that has been allotted for your visit cannot be used to treat
another patient and is time lost to our office. With that in mind and in order to keep costs as low as possible, a Medical
Appointment Cancellation Policy has been put into place.

Our policy is as follows:

We request that you please give our office a 24 hour notice in the event that you need to reschedule your appointment. This will
also makes it possible to reschedule your appointment more efficiently. If a patient misses an appointment and does not contact
us with at least a 24 hour notice, we consider this to be a missed appointment. (“No Show, No Call”) and the following fees will
be accessed:

Physical Exam: $50

30 minute visit: $35

15 minute visit $25

As a courtesy we do make reminder calls for appointments. If you do not receive your message or we have incorrect
information the cancellation policy will still be in effect.

If you have any questions regarding this policy, please let out staff know and we will be glad to clarify any questions you may
have.

We thank you for your patronage.

__________________________________________________________________________________________

I have read and understand the Medical Appointment Cancellation Policy of the practice and agree to be bound by its
terms. I also understand that this notice may be changed at any time by the practice.

_______________________________________ ______________________________________

Printed Name of the Patient Relationship to Patient (if patient is a minor)

________________________________________ _______________________________________

Signature of Patient or Responsible Party Date