Patient Document Search

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Assignment of Benefits (AOB)
This is form permits ADS to continue billing Medicare for supply items requested. Please review carefully then complete and submit to ADS.

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Authorization for Use or Disclosure of PHI
This form is used for a patient that would like to share his or her own medical record with another person/entity.

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Fee Assistance Application (Co-Pay Waiver)
This is an application form for a patient seeking assistance with their remaining costs after insurance makes payment.

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HIPAA & Notice of Privacy Practices
This form reflects how medical information about a patient may be used or disclosed and how you may obtain access to this information. Please review carefully then complete and submit to ADS.

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Download for Visually Impaired

Patient Complaint Form
This form is used for a patient that would like to submit a formal complaint.

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HIPAA & Notice of Privacy Practices
This form reflects how medical information about a patient may be used or disclosed and how you may obtain access to this information. Please review carefully then complete and submit to ADS.

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Physician Order Form
(Medicare Primary Insurance Only) This is a printable blank Order Form that must be completed by an active licensed Provider. All completed Order Forms submitted will be verified with the signing Provider.

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Request for an Accounting of Disclosures
This form is used for a patient that would like to request a list of disclosures performed on his/her own records.

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Request for an Amendment of Health Information
This form is used for a patient that would like to request a change to his/her health information that they may feel is incomplete.

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Request for Health Information
This form is used for a patient that would like a copy of his/her own medical record.

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Request for Restriction and/or Confidential Communications
This form is used for a patient that would like to request restrictions upon his/her medical information or select alternative means of communications.

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Supplier Standards
This form informs beneficiary of supplier standards providing Medicare-covered item(s).  Please review carefully then complete and submit to ADS.

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Download for Visually Impaired

Testing Log
This is a sample testing log for patients testing up to 6 times per day and would like to keep a record of their blood sugar readings.

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Testing Log 7x
This is a sample testing log for patients testing up to 12 times per day and would like to keep a record of their blood sugar readings.

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