If you are a new patient, please fill out the forms listed below in advance of your appointment to assist the staff in making sure that we have all the information necessary to provide you with quality care and treatment. Please bring the completed forms with you to your appointment.
- Patient Registration: provides us with your basic demographic and insurance information so that we can contact you as needed and bill your insurance appropriately. Please sign the bottom of this form and make sure to include proper subscriber information.
- Patient Consent for Care and Treatment: when signed, gives us permission to discuss your health and provide treatment if needed.
- Privacy Acknowledgement and Disclosure Agreement
- Medical Records Release
- Financial Policy: This form is provided to help you understand how and why billing is done. Please sign the bottom of the form as acknowledgement that you have read the information.
This notice describes the ways in which the practice may use and disclose your healthcare information. This form gives the practice authorization to release your healthcare information for purposes of treatment, payment, or healthcare operations.
- Notice of Privacy Practices (provided for you at your first visit)
- Aviso Sobre Las Practicas De Privacidad (proporcionada por usted en su primera visita)
These forms require Adobe Reader. If you do not have Adobe Reader, you may download it free here: