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Formularios para pacientes

Forms
Size
File

Authorization to Disclose Protected Health Information

Form to authorize Salus to disclose protected health information.

59 KB

Personal Representative Appointment

This form will be used for patients to appoint the persons who will represent them in various processes with Salus.

24 KB

Revocation of Authorization Form

This form is used for revoking or confirming the revocation of a previously granted authorization.

61 KB

Confidential Communication Request Form

This form is used for documenting an individual's request to use alternative channels or addresses to send their information.

30 KB

Disclosure Report Request Form

This form is for requesting a report on protected health information disclosures.

50 KB

Request for Restriction on the Use or Disclosure of Information

This form is used to request a restriction on the use or disclosure of information pertaining the individual requesting the restriction.

18 KB

Amendment Request Form

This form serves to document the request to amend the information kept by us or by our business partners.

18 KB

Grievance Form

This form will be used by individuals to file their grievances regarding our compliance with privacy practices.

23 KB

Non-urgent Medical Treatments

Consent by Proxy Form for the non-urgent medical treatment of minors.

81 KB

Advance Directives

They help us tell our relatives what kind of healthcare we wish to receive.

77 KB

Avisos y políticas para pacientes y visitantes

Forms
Size
File

Nondiscrimination and service access requirements

101 KB

Law 134-2020, known as the Protecting Patients from Surprise Medical Bills Act

89 KB

Veterans Bill of Rights Express Line, Law 78-2020 of July 31, 2020

46 KB

Policy on Service Animals

39 KB