Important Forms for your first visit

For your convenience and to speed up the process of your visit, we have provided a number of
forms for you to print and complete prior to your first visit.  By filling out this information prior to your
appointment, you will be able to accurately provide all information required.  It will also reduce your
check-in time so that we can begin services sooner.

Please print and fill out the following forms prior to your first appointment.  We ask that you do not e-
mail or mail them to our office, so that we can maintain your privacy.

Please contact the office if you have any questions.

Complete History & Physical: On this form you should provide us with background information about
any past surgeries and medical conditions.  We also ask that you list all of your current medications
and family history.

Authorization for Release of Health Service or Treatment Information:  This form allows your
insurance company or payer of services to receive the information necessary to make payments.

Patient Information Form:  We use this form to collect general information about our patients in order
to create a file for you on our computer system.

HIPAA Form:  
The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and the Confidentiality
Law.  Under these laws the practice must obtain your written consent before it can disclose
information about you for payment purposes.  For example, the practice must obtain your written
consent before it can disclose any Personal Health Information (PHI).  In addition, you must also sign
a written consent before the practice can share information for any and all treatment purposes.     

Financial Policy
We are committed to providing you with the best possible care and we are pleased to discuss our
professional policies with you at any time.  Your clear understanding of our Financial Policy is
important to our professional relationship.  Please ask any questions about our fees, financial policy
or your financial responsibility.
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