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New Patient Forms
BuiltWithNOF

These are forms that need to be completed before you can be treated.  They allow us to provide you with quality care, minimize billing problems, and meet regulatory requirements.

Clicking on the links to the four files below will download them as .pdf files.  Completing the forms in them before your arrival will help us see you more quickly.

1. Registration Form: This form provides us with basic information such as your name and address.  It also provides information and authorization for billing your health insurance plan if applicable.

2. Medical Data Form: This form provides basic health information about you such as current medical problems, past medical problems, current medications, and family medical history.  This information is important for us to be able to provide the best medical care for you

3. Information Forms: This file includes the following documents

ADVANCE DIRECTIVE INFORMATION:  This provides you information you should know about having a living will and/or a durable power of attorney for health care.  You are not required to have either of these, but we are required to provide you the information about them.

NOTICE OF PRIVACY PRACTICES:  The Health Insurance Portability and Accountability Act (HIPAA) includes a Privacy Rule which gives individuals a new right to be informed of the privacy practices of their health care providers, as well as to be informed of their privacy rights with respect to their personal health information. (For more information see our HIPAA page.) Health care providers are required to develop and distribute a notice that provides an explanation of these rights and practices.

ACKNOWLEGEMENT FORM:  We are required to have you sign a form which acknowledges that we have provided you information about advance directives and a copy of our Notice of Privacy Practices.

OFFICE FINANCIAL POLICY:  Please read this information carefully so there is no misunderstanding about your responsibilities for assuring payment for the services we provide.
 

4. Authorization Forms: This file includes the following documents

RELEASE OF INFORMATION:  This form authorizes other providers to release information to us concerning you health and health care.

AUTHORIZATION TO DISCUSS MEDICAL CARE:  We often get calls from individuals such as family members wanting to discuss a patient's care.  Completing this form will help us respect your wishes concerning these requests.

You will need a program capable of reading Portable Document Format (.pdf) files.  You can download one free at
 
http://www.adobe.com/products/acrobat/readstep2.html

get_adobe_reader

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