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Creekside Medical Clinic, Rapid City South Dakota Creekside Medical Clinic offers exceptional and personalized outpatient medical care for all ages in an environment that values communication, compassion, and respect for our patients and staff
Patient Information at Creekside Medical Clinic Rapid City SD Creekside Medical Clinic offers exceptional and personalized outpatient medical care for all ages in an environment that values communication, compassion, and respect for our patients and staff
Insurance Bill Pay - Creekside Medical Clinic Rapid City SD Online payments are being accepted at Creekside Medical Clinic In order to pay your bill online you will need the patient name, date of birth, and account number to process the payment appropriately
Creekside Medical Clinic CREEKSIDE MEDICAL CLINIC 2822 Jackson blvd, Suite 101 Rapid City, South Dakota 57702 (605) 3+1-1208 office (605) 341-3552 www CreeksídeMedícalClínic org AUTHORIZATION TO RELEASE INFORMATION Patient's Full Legal Name Mailing Address Daytime Phone Number City State DOB (mm dd yyyy) Zip Code NO CDs PLEASE - Creekside Medical Clinic sends and
Microsoft Word - HIPAAConsent. docx Signature!of!Patient,!Parent,!or!Legal!Guardian! Date!Signed! ! Creekside Medical Clinic 2822 Jackson Blvd, Suite 101 Rapid City, South Dakota 57702 605 341 1208 (office) 605 341 3552 (fax) www creeksidemedicalclinic org
Medical Examination Report FOR COMMERCIAL DRIVER FITNESS DETERMINATION Medical Examiner's Comments on Health History 7KH PHGLFDO H[DPLQHU PXVW UHYLHZ DQG GLVFXVV ZLWK WKH GULYHU DQ\ \HV DQVZHUV DQG SRWHQWLDO KD]DUGV RI PHGLFDWLRQV LQFOXGLQJ RYHU WKH FRXQWHU PHGLFDWLRQV ZKLOH GULYLQJ 7KLV GLVFXVVLRQ PXVW EH GRFXPHQWHG EHORZ 1R
creeksidemedicalclinic. org I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner's Certificate, that submission of fraudulent or intentionally false information is a violation of 49 CFR 390 35 and that submission of fraudulent or intentionally false information may subject me to civil or criminal penalties under
Microsoft Word - MedicalHxFormFinal. docx Cause of Death Age Previous Surgeries: In the spaces provided, please indicate who in your family has been diagnosed with the following medical conditions: Arthritis? Relationship Autoimmune Disease?