Aishah Covington Simms, MD

Baptist Primary Care Forms

• Advance Directives - Designation of Health Care Surrogate Form

  This link opens the official designation of health care surrogate form provided by the Florida Agency for Health Care Administration. This form allows you to designate another individual to make treatment decisions on your behalf.

• Advance Directives - Living Will Form

  This link opens the official living will form provided by the Florida Agency for Health Care Administration. This form allows you to document your instructions to your doctor to provide, withhold or withdraw life-prolonging procedures.

• Advance Directives - Overview

  This link opens the official Florida Agency for Health Care Administration website. It provides detailed information about advance directives, patient's rights, frequently asked questions and forms.

• Advance Directives - Uniform Donor Form

  This link opens the uniform donor form provided by the Florida Agency for Health Care Administration. This form allows you to indicate your desire to make an anatomical decision after death.

• Advance Directives - Wallet Card

  This link opens the Advance Directives wallet card provided by the Florida Agency for Health Care Administration.

• BPC Authorization for Use of Answering Machines

  Authorizes Baptist Primary Care to leave appointment, referral and test results information on your answering machine.

• BPC Health Care Status Authorization

  Authorizes Baptist Primary Care to release information concerning the status of your health care, including laboratory and radiology results and to discuss your treatment plan with an individual that you name.

• BPC Patient Registration and Authorization

  Captures patient demographic information, insurance information and authorizes Baptist Primary Care to prepare and submit your medical bill directly to your insurance company.

• BPC Roosevelt Medical History & Office Policies

  Provides your primary care physician with important information about your medical and family history to better diagnose, treat or prevent conditions.

• Medical Records Request or Release

  Initiates your request to have your medical records sent to another medical provider and/or to request your medical records from another provider be sent to your primary care doctor.