Patient Information Forms:

New Patients:  Please print the two forms below. Fill them out, and bring them to your first visit. Completing these forms in advance lets 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.

 

  • 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. 

     

Established Patients: 

Please use the forms above to let us know if there are any changes to your personal, insurance, or health information. 

 

Release of Medical Records:

Your medical records are secured according to HIPAA regulations.  They require your explicit permission before they can be released.  If you would like us to share them with another person, medical office, or business, please complete the release of records form below and return it to our office. (Depending on the size and purpose of the release, a duplication fee may be charged.)

 

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