Forms

Crystal Run provides online versions of commonly used forms for the convenience of our patients. Just fill out, print, and fax, mail, or bring the form you need for your next appointment.

Consent Forms:

Patient Caregiver Consent

Medical Release Forms:

Authorization for Crystal Run to Release Medical Information

Authorization for Crystal Run to Release Medical Information (Spanish)

Consent for Crystal Run to Release Pathology Slides/Block to Another Provider

Mammography Medical Release Authorization

Request for Medical Information to be sent to Crystal Run

Request for Patient Access to their PHI

Request for Patient Access to their PHI (Spanish)

Notice of Privacy Practices:

Notice of Crystal Run Privacy Practices

Patient Health Questionnaires:

Patient Health Questionnaire_PHQ2-PHQ9 — (Spanish version)

Patient Health Questionnaire GAD-7 — (Spanish version)

Vanderbilt ADHD Parent Assessment Scale —(Spanish Version)

Drug Abuse Screening Test (DAST-10) (Spanish version)

Audit-C Questionnaire (Spanish version)

Registration Forms:

New Patient Registration Forms

New Psych Patient Form

Specimen Collection Instructions:

• Semen Sample Collection
• Sputum Sample Collection
• Stool Sample Collection
• Urine Sample Collection

Medicare Annual Wellness Forms:

Medicare Health Risk Assessment Form

Medicare Health Risk Assessment Form (Spanish Version)

Health Care Proxy