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Braille Request Form
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Minimum order per form is five copies. Estimated delivery is 15-20 working days once order is placed.

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Select Item Number Item Description Quantity
CH19610000-5 Consent: Blood and / or Blood Product Transfusion(s)
CHVD011 Consent To Admission and Treatment
HS032 Discharge Instructions
HS038 ID Theft Affidavit
SYSHIPAA Notice of Privacy Practice
VD001 Authorization For Release Of Health Information Pursuant To HIPAA
VD001A Request For Confidential Communications And/Or Restrictions On Access, Use Or Disclosure Of Protected Health Information
VD001B Request For Facility Directory Opt-Out
VD001D Request For Amendment Of Protected Health Information
VD001G Request For An Accounting Of Disclosures Of Protected Health Information
VD002 Consent To Blood Transfusion
VD003 Refusal of Consent to Blood and Blood Products
VD005 Consent For Elective Female Sterilization
VD006 Information Sheet for Chorionic Villus Sampling
VD007 Info for Patients w/ a Fetus in Breech/Transverse Present
VD008 Info for Patients w/Prior Cesarean Delivery
VD009 Info for Patients Regarding Patient-Requested Primary C-Section
VD010 Consent To Operative/Invasive/Diagnostic Procedures, Anesthesia/Sedation/Analgesia - Reconsideration of DNR Orders For Surgery Or Invasive Procedures (VD010/VD010A)
VD011 Consent To Admission and Treatment
VD012 Consent To Cardiac Catheterization and Possible Intervention
VD013 Authorization To Be Audio/Visually Recorded
VD014 Acknowledgment Form To Perform HIV Test
VD017 Request to Revoke agreed upon confidential communications and/or restrictions on access, use or disclosure of PHI
VD018 Private Payor Authorization Form
VD019 Private Payor Authorization Form for Physician and Ambulatory Network Services
VD020 Request to revoke agreed upon Private Payor Restrictions on disclosure of Medical Treatment Information
VD021 Radiologic Examination and Pregnancy Information Notice for Patients
VD022 Consent for Diagnostic Radiology Procedure During Pregnancy
VD023 Pregnancy Testing Release Form
VD026 Consent For Anesthesia Services
VD027 Consent for Autopsy
VD028 Consent For The Presence Of Company Representative and Visitors
VD029 Information on Hepatitis C Testing
VD030 Consent for Donations for Fecal Transfer
VD031 Consent for Microbiotic Transfer of Fecally Derived Bacteria
VD033 Release When Patient Leaves Hospital/Facility Against Medical Advice
VD034 Acknowledgement of Person Receiving Newborn For Adoption Purposes
VD035 Release of Newborn From Hospital For Adoption Purposes
VD036 Chemotherapy/Biotherapy Consent Form
VD037 Patient Identification Verification Form
VD038 Consent to Continuous Audio / Video /EEG
VD039 Pregnancy Testing Informed Consent/Agreement High Risk Medication(s) or Procedure(s)
VD040 Consent For Hepatitis B Vaccination At Birth
VD041 Authorization to Release Placenta
VD1430 Health Care Proxy
VDLIJ011A Authorization For Release Of Information
VD-NSB-39 Consent To Out-Of-Network Services
VD-NSB-40 Cost Estimate for Out-of Network Services Responsibility for Non-Covered Services
VD-NSB-41 Standard Referral Form
VD-NSB-42 Scheduled Procedures Patient Notification Form
VD-NSB-43 Hospital Consent to Out-Of-Network Services
VD-NSB-PI44 Hospital Health Plan Participation Statement Important Information about Paying for Your Care
VDPI01 Parent's Discharge Checklist (ED Specific Document)
VDPI02 Intravenous Contrast Information Sheet
VDPI03 Patients' Bill Of Rights
VDPI04 Parents' Bill Of Rights