Forms


Download and print these forms as needed…

 

New Patient Packet

If you are looking to join our practice please download the new patient packet and either mail or fax it to us or drop it off. We will then contact you when we are ready to schedule your first appointment.

Senior form (65+): If you are 65 years old or older, please use this version.

Adult form (ages 25-65): If you are 25 years old or older, please use this version.

Young adult form (under 25): There are two options with the form. You can either print it as explained above OR you can save the Microsoft Word version to you computer, complete the form electronically, save it and send it to us via RelayHealth, our confidential web portal for communication with the office. If the electronic delivery method is chosen (which is ideal), we still need you to fill out the other pages and send up copies of the signed forms via RelayHealth. RelayHealth must be set up prior to using it, but it’s very easy and is explained here, just scroll down.

Young adult print form

OR

Young adult electronic form AND print, complete, sign and send these

 

Interval History Forms:

A new interval history form must be completed before each annual physical. We will send you a blank form with your reminder letter, but if you need an extra for any reason, they can be found here.

Female form

Male form

 

Record Releases:

If your records are at another office and you want to have them sent to us, use this form.

If you are trying to get your records from us and sent to another office, use this form.

(Note: this second form requires a $25 fee)

 

Authorization for Disclosure:

Patient Health Information Disclosure

 

Consents

This three-in-one form covers acknowledgement of HIPPA policies (see below), RX hub inquiry and grants permission to communicate with other physicians and providers.

 

HIPPA

See HIPPA policies here.