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	Forms To make your office visit go quicker, you are invited to download the forms provided here to fill out in the comfort of your own home. Please be complete and accurate. Inaccuracies and errors may be rejected by your insurance company and delay your surgery. Forms are offered in the Adobe Acrobat format. Adobe Reader is available as a free download from Adobe's web site. You may quickly and easily fill out the forms on your computer, then print them out and bring them with you when you come in for your appointment. The forms may not be saved in this format so you need to have all of your information at hand when you sit down to fill them out and print them. If you wish, you can print the forms and then fill them out by hand at your convenience prior to coming in for your appointment. There are three patient packets. General Surgery Patient Packet includes; Patient Information Form, General Surgery Patient Questionnaire, Release of Information and Payment of Benefits Form, our Patient Privacy Statement and the Receipt of Privacy Statement Form. Breast Surgery Patient Packet includes; Patient Information Form, Breast Surgery Patient Questionnaire, Release of Information and Payment of Benefits Form, our Patient Privacy Statement and the Receipt of Privacy Statement Form. Varicose Vein Consult Form Patient Packet includes; Patient Information Form, Varicose Vein Consult Form General Surgery Patient Questionnaire, Release of Information and Payment of Benefits Form, Our Privacy Statement and the Receipt of Privacy Statement Form. All of the forms are also available as individual forms; Patient Information Form includes contact and health insurance information. Breast Surgery Patient Questionnaire is a medical history form for our breast surgery patients. General Surgery Patient Questionnaire is a medical history form for our general surgery patients. Varicose Vein Consult Form is a medical history form for varicose vein problems. Release of Information and Payment of Benefits Form is required for assigning benefits and payments from your insurance company. Patient Privacy Statement. This is our privacy policy statement, in accordance with Federal HIPAA regulations Receipt of Patient Privacy Statement Form New Patient Check List All new patients should review and complete the following checklist. Be sure to bring the following information along with you on your appoint to our office: Picture ID Insurance Card Copay for a Specialist Referral (if required by your insurance plan) Mammogram films (Breast patients only) (Make sure mammogram report is included with the films). Complete new patient paperwork. Current list of ALL medications Please call (404) 508-4320 if you have any questions regarding any of this information. Thanks, we look forward to seeing you.
	DeKalb Surgical Associates ©2010 DeKalb Surgical Associates 2665 North Decatur Road Suite 730 Decatur, Georgia 30033 (a suburb of atlanta) Phone: (404) 508-4320 Fax: (404) 508-4112

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