Patient Registration Forms & Privacy Notices
If you are a new patient, please fill out the registration 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 Financial Communications
- Patient Consent to Treat
- HIPAA Acknowledgement and Disclosure Consent - Patient Consent and Notice of Privacy Practices: allows us to treat you; for Medicare patients, allows us to release information as requested to the Social Security Administration; and provides acknowledgement of having received the Notice of Privacy Practices. Please initial the Privacy Practices statement (at bottom of form) and sign and date the bottom of this form
- Medical Records Release
- Welcome Letter
- Health Questionnaire
Patient Rights & Responsibilities
We respect our patients’ dignity and pride. This document will explain your patient rights and responsibilities. It is part of your patient registration and is an important part of your health care plan.
This privacy notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
- Notice of Privacy Practices (provided for you at your first visit)
- Aviso Sobre Las Practicas De Privacidad (proporcionada por usted en su primera visita)
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