New Patients

Please print the required forms below ("General Information and Health History" and "Notice and Acknowledgement of Privacy Practices").  Fill them in, and bring them to your first visit. Completing them in advance allows you to carefully consider the questions, provide complete answers, and it saves valuable time during the appointment. You may also bring any supplemental information that you feel is important.

 

Established Patients

Please let us know if there are any changes to your personal, insurance, or health information. Print the appropriate forms below and fill in the updated information. Bring the form and any other related information to your next visit so we can update our records. This will allow us to provide the best care possible, and reduce errors in billing.

 

Release of Medical Records

To request the release of your medical records from our office, plese complete the Release of Records form below and send it to our office. To revoke a prior authorization for records release, please complete the Revocation of Records release form below and send it to our office.

 

New Patient Forms:

General Information and Health History


(Required for all new patients)
This form provides the basic health history and demographic information that we need to create your medical record and begin providing services. Please take the time to answer the questions completely.

 

Notice and Acknowledgement of Privacy Practices


(Required for all new patients)
The first two pages of this document are a Notice of Privacy Practices.  It describes how our clinic may use or disclose your personal medical information.  The last page of this document is a form to acknowledge receipt of the Notice of Privacy Practices.  All patients must sign the acnowledgement form and return it to the clinic before we can see you. 

 

Special Forms:

Release of Records


(Use only if needed)
Complete this form and send it to the clinic to authorize the release specific health information to others for specific purposes.  Use it only if you need to share your health information with others who don't normally have access under the Notice of Privacy Practices document.

 

Revocation of Release of Records


(Use only if needed)
Complete this form and send it to the clinic to revoke disclosure authorization granted by a Release of Records form.  This form does not impact normal information releases described in the Notice of Privacy Practices document.