Notice and Acknowledgement of Privacy Practices
Protecting the privacy of your medical information is required by law and we respect and carefully abide by that law. You should carefully read these forms – and then acknowledge your acceptance of their conditions by signing should you choose to do so. These forms must be completed and returned to the clinic at the time of a patient’s first visit. You should list names of people who are permitted access to your (or the patient’s) protected health information. No information can or will be shared with anyone who is not listed on this form. Privacy Policy
New Patient Information Form
This form is for all new patients to fill out and bring to the clinic upon their first visit. This form gives you the option of (1) filling out the form on your personal computer, printing it and bringing it with you, or (2) printing out a blank form, filling it out with a pen and bringing it with you.
Forms for Returning Patients
The Information Change form should be filled out when there is any type of change in the patient’s information, whether it is an address, policy number, etc. The entire form must be completed regardless of the information that has changed. Please present the form upon your arrival to see a doctor. Keeping your information accurate and current allows us to provide you with better healthcare and ensure your claims are paid promptly.
Medical Record Request
Please allow 10 days for your request to be processed. This form is for patients who choose, for any reason, to have their medical records transferred to another health care provider or retain a copy for their records.