All Patients (additional forms for New patients are below)
In addition to completing the forms provided here, all patients must click on Preparing for your visit and follow the instructions.
All patients should complete the following forms, if applicable:
- Records Release and Authorization to Disclose PHI - please complete this form if you have records at another facility that are pertinent to your visit to our office; if possible, please bring copies of your records with you; if records are being faxed, please ensure they arrive at least 24 hours prior to your scheduled appointment
- United Healthcare Laboratory & Pathology Services Consent Form - any patient with United Healthcare insurance is required to review and sign this form prior to every office visit
Important: Note that patients not seen in our office within the past 3 years are considered new patients.
New patients must review and complete the following forms prior to their visit (these are in addition to the forms listed under All Patients above):
- New Patient Registration and Medical History Form - please print and complete all 6 pages
- Notice of Privacy Practices for Protected Health Information - please review, then print and sign the Acknowledgment of Receipt of Notice of Privacy Practices
- Notice of Nondiscrimination and Accessibility Requirements - please review, then print and sign page 2
- Confidential Communication Authorization - please print and complete
- Financial Policy - please review, then print and sign page 4