Forms

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

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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.

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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.

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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.

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Existing Patients

Existing patients should arrive at the clinic 15 minutes prior to their scheduled appointment. If any of your patient information has changed since your last visit, including your insurance, make sure to note that information on our Information Change Form. If your insurance has changed, please bring your new insurance card with you to the clinic.

  • Photo ID
  • Insurance Cards
  • New Patient Form or Information Change Form
  • List of all medicines you are taking — prescription and over the counter
  • Be prepared to pay all co-pays and deductibles

New Patients

At the time of your appointment, new patients should bring:

  • Photo ID
  • Insurance cards
  • New patient forms
  • List of current medications
  • Co-payments and deductibles

Patient Messages

Our goal is to return your message the day it is received depending on the time received and clinic schedule. Please allow 24 hours for messages to be returned. You may submit messages via our secure Patient Portal.