Flagstaff Family Physicians, P.C -Robert Yee, M.D.

Available Forms

Alcohol Questionnaire- AUDIT -C *new patient form* Depression Health Questionnaire (PHQ-9) *new patient form* HIPAA *new patient form* Intake Questionnaire *new patient form* Medical Records Release *new patient form* Medicare Wellness Survey (Medicare Required) Patient Registration Form *new patient form* Payment Policy *new patient form* Physical Exam Form Required

HIPAA new patient form

I acknowledge that I received and read the Notice of Health Information Practices. I understand that my healthcare provider participates in Health Current, Arizona�??s health information exchange (HIE). I understand that my health information may be securely shared through the HIE, unless I complete and return an Opt Out Form to my healthcare provider. *

Name of patient:

To respect your privacy, please tell us whom we may contact regarding your medical information. If you do not wish for us to share information with anyone other than yourself, write "self" then type your name and date below. *

Please write name of the person, relationship, and phone number of who you'd like to share information with

We may communicate the following with the person indicated above regarding: *

Lab & Radiology Results

Prescription Information

Appointment Reminders

Billing Information

All of the above

Patient signature & date *

* Required field