Spanish Patient Forms

Please correct the errors described below.

Formade Informacion Para Paciente Nuevo

Problemas Medicos:

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Cirujia Importante:


***** For CMC Office use only *****

Step 1 --> Return to CMC Business Office:

  • Check with Business Office regarding previous balance. All previous balances must be paid out prior to accepting patient.
  • Please Check:

Step 2 --> MD/PA/NP Review:

Step3 -> Contact Patient:

  • Accepted (No Outstanding Balance) Declined Nursing staff to contact patient.
  • Accepted With Outstanding Balance: Nursing staff to forward form to appropriate Account Rep who will contact patient.

Patient Contacted ->

Step 4 ->

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