SGI Established Patient Paperwork

Southeastern Gastroenterology Financial Policy
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Patient's Name
Patient's Signature

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Today's Date

MonthDayYear
Date

Southeastern Gastroenterology HIPAA Acknowledgement
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Signature

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Today's Date

MonthDayYear
Date

Southeastern Gastroenterology Records Release
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Patient Name
Patient's Date of Birth

MonthDayYear
Date
Last 4 digits of patient's social security number
Patient's Signature

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Information NOT to be disclosed
Email
example@example.com

Southeastern Gastroenterology Consent to Treatment Form
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Signature

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Today's Date

MonthDayYear
Date

Southeastern Gastroenterology Office Visit Cancellation Policy
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Today's Date

MonthDayYear
Date
Signature

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Should be Empty: