Phone: 916-817-2649
Fax: 916-817-6943 |
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Download Forms for your visit
It is very important for all patients to have their previous Ob/Gyn Medical Records sent to our
new practice prior to your first visit with Dr. Haskins. Please do this as soon as possible, even
if your office evaluation is not due for quite some time. Having your prior medical records will allow
us to care for you in the interim. Without your records we cannot refill prescriptions or answer minor
questions by telephone.
Patients previously seen at the Women’s Center for Health, UCD Medical Group Folsom should use the following
form:
Authorization for Release of Health Information – UCD ( MS Word |
HTML )
Patients cared for at other facilities should use the following form:
Authorization for Release of Health Information – Other ( MS Word |
HTML )
PLEASE COMPLETE ALL BOLDED ITEMS, MAKE SURE YOU INITIAL THE TWO LINES THAT REQUIRE INITIALS. MAIL OR HAND CARRY
THE FORM TO YOUR PRIOR HEALTH CARE FACILITY. Prior UC Davis Women's Center patients can mail these request forms directly to 1370
Prairie City Road, Folsom, 95630 -or - they can be hand delivered to the practice occupying that location -or- they can be faxed
to that location at 916-355-1216. You must allow at least two weeks to elapse before we will have a copy of the pertinent parts
of your prior medical record.
Other forms you may download prior to your office visit:
Notice of Privacy Practice Form (HIPAA) ( MS Word |
HTML )
Receipt of HIPAA Policy Form ( MS Word |
HTML )
Prior to your visit, please print the Patient Registration Form and the Initial Intake History. Take your time completing them in detail, and bring them with you to your appointment.:
Patient Registration Form ( MS Word )
Medical History Form ( MS Word )
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