Patient Forms

Patient Registration Form (PDF) – Information required from our new patients.

Patient Medical History (PDF) – including medications,  allergies, past/current medical conditions, hospitalization and surgery history, family and immunization history.

Financial Policy (PDF) – This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.

Authorization for Release of Medical Information (PDF) – Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.

Notice of Privacy Practices Acknowledgement Form (PDF) – Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.

Patient Rights Information Packet (PDF) – This informational packet explains your rights and our responsibilities to you, your choices about what information we can share and how we typically use and share your information.

Virtual Visit Policy (PDF) – This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.