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