Clinic Forms & Documents

Immunization

  1. Adult Immunization Schedule English (PDF)
  2. Adult Immunization Schedule Spanish (PDF)
  3. Travel Clinic Services Flyer (PDF)

General

  1. Form - Patient Registration (OCGN-007) (as of December 2021)
  2. Assignment of Medical Insurance Benefts.pdf
  3. NC Minor Consent Law 10-6
  4. Form - Patient Right of Access - Patient Request for Health Information 11-1-2021

Health Information Exchange

  1. Form - CCHIE Opt-Out (English) (as of October 2020)_202011190852570538.pdf
  2. Form - CCHIE Opt-Out (Spanish) (as of October 2020)_202011241222106051.pdf
  3. Form CCHIE Revoke Previous Opt-Out (English) (as of October 2020)_202011190852507388.pdf
  4. Form - CCHIE Revoke Previous Opt-Out (Spanish) (as of October 2020)_202011190853010539.pdf
  5. Health Information Exchange Brochure English
  6. Spanish- Health Information Exchange

Medical Records

  1. Demographic Change Request.pdf
  2. Release of Information Authorization Form.pdf

HIPAA

  1. Health Information Exchange- updated june 2021
  2. Copy of Health Information Exchange (spanish)- updated june 2021
  3. HIPAA - Onslow County Government Privacy Guidelines Notice of Privacy Practices (Spanish) (effective 3-10-22)
  4. HIPAA - Onslow County Government Privacy Guidelines Notice of Privacy Practices (English)(effective 3-10-2022)