General Medicine Clinic: Dr C Osuji - Publicforms

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Available Forms

Agreement to Receive Chronic Care Management Services for Medicare patients Appointment request Asthma Control Test Balance self-test (please fill prior to every visit and press send) por favor, llene antes de cada visita y pulse enviar Checklist for Medicare Annual Wellness Visit Controlled med contract Cough/cold/sinus infection COVID-19 Patient Screening Questionnaire COVID-19 poner en pantalla COVID-19 QUESTIONNAIRE COVID-19 SCREENER Depresión Employment form Espanol vacuna COVID-19 Flu History - Please fill out prior to your visit. For 2nd visit and after, please update New patient form New pt Spanish OB/GYN ANNUAL INTAKE Patient Health Questionnaire - Depression Screening Patient/Health Care Provider E-mail/Texting Consent Reason for your next office visit Record request Referral request (requests are processed in 5 working business days) If urgent request needed, please call office to pick up btw 12 noon at 4 pm Refill request Spanish New Patient Telehealth Consent Telephone or message Consultation (for Clinic patients only) Video conference for patients VITALS

Referral request (requests are processed in 5 working business days) If urgent request needed, please call office to pick up btw 12 noon at 4 pm

Name *

Phone number *

Email address *

Insurance company *

Insurance company Address and provider phone number *

Insurance ID# *

Group # *

Specialty

Physician information *

Please add name of physician, address, phone and fax numbers and NPI number

Diagnosis *

Procedure codes

Name of Specialists? Clinic *

Is physician in network with your insurance?

You can also request that the information be faxed by specialist needing the referral to 281-859-7105

* Required field