***** Patient Care Forms *****
  1. 106808 - Adult History Questionnaire
  2. Health Care Power of Attorney
    1. 901109 - Health Care Power of Attorney
    2. 901424 - Health Care Power of Attorney (Spanish)
  3. Living Will
    1. 75135 - Living Will
    2. 900533 - Living Will (Spanish)
  4. Authorization to Disclose PHI
    1. 900010 (PDF) - Authorization to Disclose Protected Health or Billing Information - PDF
    2. 900010 (Word) - Authorization to Disclose Protected Health or Billing Information - Word
  5. Health Care for a Minor Authorization (Eng and Span)
    (900255) and (900574) - ARCHIVED
  6. 900133 - Outpatient Information/Consent to Treat - Adults
  7. 900911 - Outpatient Information/Consent to Treat - Adults (Spanish)
  8. Outpatient Information/Consent to Treat - Pediatrics (Eng and Span)
    (84850) and (84919) - ARCHIVED
  9. 74016 - Personal Data
  10. 802733 - Pediatric Personal Data Sheet
  11. 73839 - Pediatric History Questionnaire
  12. 805868 - Pediatric History Questionnaire (spanish)
  13. Permission to Communicate with Family and Friends Form/Voicemail (Eng and Span)
    (900136) and (73648) - ARCHIVED
  14. PrimeCare - 78276 - PrimeCare - Emergency Department Referral
  15. PrimeCare - 78275 - PrimeCare - Sports/Activity/School Medical History Questionnaire
  16. 900932 - Authorization to Disclose Health or Billing Information (Spanish)
  17. 73619 - Medication List
  18. 900600 - Novant Medical Group Personal History Review
  19. 901254 - Occupational Medicine/Workers Compensation Registration Form
  20. 75811 - Sleep Disordered Breathing Questionnaire
  21. 900639 - Easy Screener Epworth Sleepiness Scale
  22. 75377 - Berlin Questionnaire
  23. Managed Care Waiver Advanced Notice (Eng and Span)
    (4554) and (75246) - ARCHIVED
  24. 900047 - Inactivated Influenza Vaccine Outpatient Flu Vaccination Record 2017-2018
  25. 901048 - Intranasal Flu Vaccine Outpatient Flu Vaccination Record 2014-2015
  26. 900481 - HIPAA Accounting of Disclosures Log
  27. 73995 - Women's Health History Questionnaire
  28. Carolina Hand Center: 801230 - Carolina Hand Medical Questionnaire
  29. 84893 - Orthopedic Patient History
  30. 800822 - Infectious Disease Specialists: New Patient History Questionnaire
  31. 800198 - Presbyterian Pediatric Cardiology: History
  32. Acknowledgment of Receipt of Joint Notice Privacy Practices
    (83535) - ARCHIVED
  33. Hawthorne Cardiothoracic & Vascular Surgeons: 801604 - Patient Evaluation
  34. Hawthorne Cardiothoracic & Vascular Surgeons: 801605 - Office Appointment Request
  35. 801535 - Communicating Your Health Information
  36. Hawthorne Cardiothoracic & Vascular Surgeons: 801528 - Patient Pre-Surgical Questionnaire
  37. 802430 - Adult Patient History
  38. 106808 - Adult History Questionnaire
  39. 800132 - New Patient History
  40. 802872 - Charlotte Colon & Rectal - New Patient History
  41. 900009 - Request to Exercise Privacy Rights
  42. 901295 - Request to Exercise Privacy Rights - Spanish
  43. 802793 - Admission Face Sheet - PWMC
  44. 801798 - Primary Care Notification Letter
  45. 802109 - Confidential Health History Questoinnaire - PWMC
  46. 84270 - Managed Care Waiver
  47. 803143 - Psychiatric Consultation Form
  48. 803143 NHUVA - Psychiatric Consultation Form NHUVA
  49. 802124 - BHOP Privacy Disclosure Information
  50. 802102 - Child/Adolescent Developmental History - PWMC
  51. 803119 - Consent for Minor with Custofy Verification - PWMC
  52. 802860 - Authorization to Obtain Patient Records from Outside Facility - PWMC
  53. 801799 - Authorization to Release Health Information - PWMC
  54. 803199 - Medical History Questionnaire
  55. 101014 - Ortho & Sports Med - Patient History Form
  56. 900133 - Ortho & Sports Med - Outpatient Info Consent to Treat
  57. 803198 - Pain Mangement DIRE Score
  58. 803197 - Pain Management New Patient Intake Survey
  59. 900597 - Pain Management Agreement
  60. 803196 - Pain Management Patient Check-Out
  61. 803195 - Pain Management Return Visit Note
  62. 802829 - Well - Male Exam
  63. 802830 - Well - Woman Exam
  64. 805364 - Headache New Patient Questionnaire
  65. 805365 - Headache Pre Visit Medication List
  66. Sports Performance Packet
  67. 1111 - Text appointment reminders consent
  68. Pediatric proxy request
  69. 802422 - Urology Review of Systems
  70. 803728 - Patient Request for Access to Protected Health Information
  71. 802499 - Medicare Health Risk Assessment
  72. 83531 - NC Notice of Privacy Practices Brochure - English
  73. 83528 - NC Notice of Privacy Practices Brochure - Spanish
  74. 900255 - Health Care for Minor Authorization Consent - English
  75. 900574 - Health Care for Minor Authorization Consent - Spanish
  76. 700317 - All States Patient Bill of Rights - English
  77. 700318 - All States Patient Bill of Rights - Spanish
  78. 84913 - Neurosurgery New Patient History
  79. 1108_SA - Pre-Surgery Guide (Surgical Associates)
  80. 801636 - Rheumatology & Arthritis Patient History
  81. 75284 - FMLA Form Completion Request
  82. 801720 - Acknowledgement of Receipt of Notice of Privacy Practices
  83. 800299 - Neurology Sleep Questionnaire
  84. 806235 - Gestational Diabetes Questionnaire
  85. 802463 NHUVA - GDM Initial Assessment
  86. 806203 - Pediatric Endocrinology New Patient History
  87. 806370 - Annual Wellness Visit Patient Questionnaire
  88. NHUVA NHUVA Nutrition Therapy - New Patient History
***** ONLY for Radiology Use *****
  1. 1754 - Breast MRI Worksheet
  2. 900695 - CT/Radiology Diagnostic Questionnaire
  3. 900686 - MRI Patient Questionnaire
  4. 800238 - Patient History for DEXA Scan
***** Other Forms ***** Visit http://www.secretary.state.nc.us/ahcdr/Forms.aspx to download following forms:
  1. Advance Instruction for Mental Health Treatment
  2. Organ Donor
  3. Advance Health Care Directive Registry
  4. Revocation Form