Patients of Colorectal Surgery Associates are asked to fill out a new patient registration form, patient history, a doctor/patient agreement, and two HIPAA (Authorization for Use/Disclosure of Health Information) release forms.  These forms may be printed out from the links below and either brought to your appointment or faxed to us prior at 478-475-9780.

Required for your first Office Visit

Patient Registration Form  – Personal and insurance information

Patient History Form – Personal and family medical history

Hereditary Cancer Risk Assessment

Medications List – Medications you are currently using; both prescription and non-prescription

Privacy Notice – Notice about your health information privacy rights

Records Release Consent – Names of person(s) you consent us to release your records to.

CSA Records Release – approval to release medical records to Colorectal Surgery Associates

Financial Policy – Colorectal Surgery Associates financial policy acknowledgement

Central GA Health Exchange Notice – Permission to create a Health Exchange record to share with your healthcare providers

Explanation of Insurance Coverage of Office Procedures

 

SURVEY FOR PATIENTS

Colorectal Surgery Associates Survey – We ask that after you visit, please take the time to fill out our short survey – to let us know how we can serve you better.