Board Certified Internal Medicine
Board CertifiedInternal Medicine

Forms / Links

Assorted Forms:

New Patient Forms
NEW PATIENT STATUS 21NOV2017:
Currently accepting new patients in our Bluewater Bay office, and for house calls at the following assisted care living facilities:
Beehive Niceville, Brookdale Niceville, Superior Niceville, and Meridian Ft Walton Beach.
new patient pack ccm.pdf
Adobe Acrobat document [936.9 KB]
Medicare Chronic Care Management Introduction Letter
All Medicare patient encouraged to enroll in this important benefit.
ChronicCareManagementInvitePakCoverLette[...]
Adobe Acrobat document [87.1 KB]
Medicare Chronic Care Management Consent form
Dr. Kenneth W. Ponder consent form.pdf
Adobe Acrobat document [234.1 KB]
Medicare Chronic Care Management Tricare for Life / Federal BCBS additional info
ChronicCareManagementTricarePaymentLette[...]
Adobe Acrobat document [62.2 KB]
Disabled Person Parking Form
disabled_person_parking_form.pdf
Adobe Acrobat document [192.7 KB]
Controlled Medication Management Agreement
controlled_medication_management_agreeme[...]
Adobe Acrobat document [62.3 KB]
Assisted Care Living Facility Form 1823
AHCA_Form_1823.pdf
Adobe Acrobat document [231.6 KB]
Privacy Policy
HIPAA_notice_of_privacy_practices_201309[...]
Adobe Acrobat document [91.8 KB]
Living Will / Health Care Surrogate Forms - FLORIDA
To download living will and health care surrogate forms for other states, visit http://www.caringinfo.org/i4a/pages/index.cfm?pageid=3289
fl_advance_directive_health_care_decisio[...]
Adobe Acrobat document [106.9 KB]
Do Not Resuscitate Order
A Do Not Resuscitate Order (DNRO) is a form or patient identification device developed by the Department of Health to identify people who do not wish to be resuscitated in the event of respiratory or cardiac arrest.

Important! In order to be legally valid this form MUST be printed on yellow paper prior to being completed. EMS and medical personnel are only required to honor the form if it is printed on yellow paper.
dnro-updated-form.pdf
Adobe Acrobat document [133.6 KB]

Contact Us:

Bluewater Medicine
4566 E Hwy 20 Ste 103
Niceville, FL 32578

 

Phone: +1 850 897-1223+1 850 897-1223

Fax:     +1 888 423-5018

bluewatermedicine@gmail.com

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