Be Prepared and Informed With AWH’s Patient Forms and Documents

 

At Adriatica Women’s Health (AWH), we strive to make every visit productive and efficient. Plus, we’re dedicated to making sure you’re informed, up-to-date, prepared and empowered. With that in mind, we’ve created this clearinghouse of downloadable forms and documents for your convenience and highest-quality care.

New-Patient Paperwork

• Demographics Sheet
• Financial/Office Policies
• Notice of Privacy (HIPAA) Practices
• HIPAA Consent Form
• Patient Intake History
• New Patient Packet – Annual Appointment
• New Patient Packet – Problem Appointment
• New Patient Packet – Prenatal Appointment

 

Established-Patient Annual Paperwork

• Interval Gynecological History
• Demographics Sheet
• Financial/Office Policies
• Notice of Privacy (HIPAA) Practices
• HIPAA Consent Form

 

Pregnancy Paperwork

• Prenatal Genetic Screen
• Preparing For Pregnacy

 

Authorizations

• Consent to Treat Minor Patient
• Confidentiality Agreement for Minor Patient

 

Medical Records

Patient Instructions for Medical Record Requests

Effective October 30th, 2023, Adriatica Women’s Health has partnered with HealthMark Group to ensure the accurate and timely completion of medical record requests.

How?

Requests should be submitted electronically to HealthMark’s Request Manager at https://requestmanager.healthmark-group.com. Once logged in, select “Submit Request” from the menu options and enter all required fields to provide an authorization directly to HealthMark. Your medical record request will be processed, and a notification will be sent via mail or email once complete and available for download.

Any questions?

Please log in to the Request Manager linked above for status updates or to chat with support. If you have any questions, you may contact HealthMark at 800-659-4035 or status@healthmark-group.com.

For urgent requests (needed within the next 24 hours) please contact the office directly or submit the form below directly to the office:

Records Request Form – to request a copy of your Adriatica Women’s health records.

Records Release Form – to request your previous records be sent to Adriatica Women’s Health please fax this form to your previous medical provider for processing

Patient Instructions for FMLA/Disability Requests

Adriatica Womens Health has partnered with HealthMark Group to ensure the accurate and timely completion of your FMLA and/or Disability forms.

How?

Requests may be submitted electronically to HealthMark’s Request Manager at https://requestmanager.healthmark-group.com. Once logged in, select “Submit Request” from the menu options and enter all required fields to submit a valid authorization. Each form requested for completion will require a $35 fee to be paid directly to HealthMark. Estimated turnaround time will be 48-72 hours.

If an email is provided, you will receive a response directly from HealthMark notifying you of the prepayment invoice. After payment, the completed forms may be downloaded directly through HealthMark’s website, or provided directly to you through an agreed to delivery method (i.e. secure email, mail, etc.).

Any questions?

Please log in to Request Manager for status updates or to chat with support. If you have any questions, you may contact HealthMark at 972-895-2138 or email fmla@healthmark-group.com.

Patient Survey

• Patient Survey

 

Surgery Guide

• Preparing for Surgery

 

Notices

• Nondiscrimination Statement

 

For more information, or to schedule an appointment, call (972) 542-8884. You can also schedule an appointment using our easy online form.