PATIENT VISIT FORMS

These forms must be completed annually or whenever you have a change to your personal or medical information.  They must also be completed if you have not had an office visit prior to your procedure.

Patient Information Form
Practice Privacy Statement
Consent and Understanding
Release of Medical Information
Review of Systems Form

BILLING FORMS

Procedure Financial Form
Financial Assistance Application Form

Patient Information Form (click to view and print)

The Patient Information form provides us with your demographic information as well as your current list of medications.  Please print and complete this form and bring it to your office visit or procedure.

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Practice Privacy Statement (click to view and print)

The Practice Privacy Statement details how your medical information may be used and disclosed and how you can access this information.  Please print, read and sign the statement and bring it to your office visit or procedure.

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Consent and Understanding (click to view and print)

The Consent and Understanding form gives your consent to our Privacy Statement, consent for us to provide your care, consent to release information and to process your insurance claims, and outlines our Financial Policy.  Please print the form, sign it, and bring it to your office visit or procedure.

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Release of Medical Information (click to view and print)

The Release of Medical Information form gives us permission to release and discuss your medical information to only people you specify.  Please print and complete this form and bring it to your office visit or procedure.

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Review of Systems Form (click to view and print)

The Review of Systems Form gives the physician a snapshot of your current health and medical history.  Please print and complete this form and bring it to your office visit.

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Procedure Financial Form (click to view and print)

The Procedure Financial Form outlines the steps you take to make sure you receive the highest level of coverage from your insurance company.  You will receive this form at the time your procedure is scheduled.

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Financial Assistance Application Form (click to view and print)

A completed Financial Assistance Application Form (along with the necessary documents) allows our Financial Counselor to determine if all or a percentage of your patient balance can be adjusted off due to financial hardship.

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