Patient Document Search

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  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 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.

Download  - Non-Medicare

Download for Medicare Primary Insurance ONLY 

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.

Download 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.

Download

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.

Download Download for Visually Impaired

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