PATIENT FORMS

New Patients:

Set up an Appointment: (606) 219-4184 

Forms:

FYI- You can get results faster if you download and fill in these forms before your appointment.  Please drop them by our office or FAX to: 606-678-8368 
For All Patients:
Authorizations for Release of Information (so KBC can get your Prior Images & Reports):​
Insurance & Payment Policy Agreement​
Optional Patient Forms:
If you want to grant access of your Medical Records/Reports to your Approved Friends or Family Members, please fill in: HIPPA Release Form
Acknowledgement of  the "Self Pay" Option and Responsibilities
If You are Pregnant, please fill in: Pregnancy Consent Form
For Referring Physicians:
KBC-SFI Exam Order Form
 
ICD-10 Lookup Codes for ABI, CT Lung Cancer Screening and DEXA
2021 ©  KENTUCKY BREAST CARE.
ALL RIGHTS RESERVED.
Phone:  606-219-4184
Fax:  606-678-8368
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