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Advance Directive North Carolina

Includes forms for Healthcare Power of Attorney and Living Will

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Alternative Communication and Privacy Form

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Authorization to Disclose Health Information

Patient permission to provide Carolina Digestive’s records to others.

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Authorization to Disclose Health Information (Revocation)

Patient request to stop permission to provide records.

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Endoscopy Center Pre-Packets

Carolina Endoscopy Center

Carolina Digestive Endoscopy Center

Hospital Endoscopy Center

New Patient Registration Forms

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New Patient Appointment Referral

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Patient Interview Form

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Patient Responsibility

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Patient Responsibility (Spanish)

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Patient Responsibility (Vietnamese)

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Patient Rights

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Patient Rights (Spanish)

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Patient Rights (Vietnamese)

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Privacy Practices Notice

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Open Access Referral Form (English)

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Open Access Referral Form (Spanish)

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Request for Release of Medical Information

For release of other physician’s records to Carolina Digestive.

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GoLytley/NuLytely

AM 2 day

PM 2 day

AM Full gallon

PM Full gallon

AM Reduced

PM Reduced

MiraLAX

AM

PM

MoviPrep

AM

PM

OsmoPrep

AM

PM

Prepopik

AM

PM

SuPrep

AM

PM