ZAVALA INTERNISTS, S.C.


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FORMS



The links below provide access to some of our more common forms. Please feel free to download and/or print these forms.





please click on one of the links below



Pre Surgery Questionnaire



Please complete the Pre-Surgery Questionnaire prior to your appointment. Don't forget to print the completed form and bring it to your appointment. (For pre-surgical patients only)



Medical Records Release Form I



This Medical Records Release Form is used to request records from one of our physicians. The records will be forwarded to the individual you specify on the form. (Please be aware, you could incur a copy fee for this request)



HIPAA - Notice of Privacy Practices



This notice describes how medical information about you may be used and disclosed and how you can get access to this information.



Medical Records Release Form II



Medical Records Release Form II is used to request records from a physician outside of our office. Per this release form, the records will be forwarded to our office. (Charges, if any, for this service are determined by the providing office)



Health Information Exchange - Reverse Opt Out



The Reverse Opt-Out Form should be completed if you wish to retract a previously completed Opt-Out Form.



Health Information Exchange - Opt Out



The Opt-Out Form should be completed if you choose NOT to allow other participating medical facilities access to your records for medical treatment.



1725 West Harrison Street, Suite 318

Chicago, Illinois 60612


(312) 942-6647