Notice and Acknowledgement of Privacy Practices
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
Requests are processed on Friday by Health Port. 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 any other location or healthcare provider.