Patient Forms
Notice of Privacy Practices
The Notice of Privacy Practices explains how your health information may be used and disclosed by Randleman Medical Center and how you can access your individually identifiable health information. Patients are encouraged to review this notice carefully to understand how their medical information is protected and managed.
Authorization for Release of Medical Information
The Authorization for Release of Medical Information allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. This form must be completed if you would like your medical information shared with others.
Authorization and Consent for Treatment
The Authorization and Consent for Treatment is required for all patients. By completing this form, patients provide consent for medical treatment, communications (including phone calls, emails, and text messages), and acknowledge agreement with financial responsibility for services rendered.
Autorización y Consentimiento Para el Tratamiento is also available for Spanish-speaking patients.
Preferred Contacts
The Preferred Contacts form allows patients to identify individuals who may be contacted regarding their care. Completion of this form is encouraged but not required.
Contactos Preferidos is available in Spanish.
Financial Policy
The Financial Policy outlines the patient’s full financial responsibility for all medical services received, regardless of insurance eligibility or coverage determinations. Patients are encouraged to review this document carefully to understand billing and payment expectations.
Language Services
Randleman Medical Center provides free language assistance and accessibility services in accordance with Section 1557 of the Affordable Care Act, including qualified interpreters, information in other languages, and communication aids for individuals with disabilities; patients who need these services may contact their provider or the office manager at their care center, and the Notice of Nondiscrimination and Accessibility Requirements is available below in both English and Spanish.