Patient Forms and Notice of Privacy

If you would like to save time during your visit, you may download any of our four information forms and fill them out to bring with you. To do this simply click on the links below for either Microsoft Word (MS Word.doc) or Adobe Acrobat  (.pdf) formats as you choose. You may then print out the blank forms and fill them out at your convenience before coming to the office. You will need Adobe Acrobat Reader to do this, and can obtain it for free at the Adobe site below.


FMLA and Disability Forms Policy


Please allow 3-5 business days for medical forms to be completed.


A fee of $15 applies to each form completed on your behalf.

Click on any of the forms below to download.

Background and History Form (.pdf)

 Patient Registration Form (.pdf)

Consent of Minor Child Form (.pdf)

Privacy Policy Form (.pdf)


Notice of Privacy Practices


This practice creates a medical record of your health information in order to treat you, receive payment of services delivered, and to comply with certain policies and laws.  We are also required by law to provide you with this Notice of our legal duties and privacy practices.  In addition, the law requires us to ask you to sign an Acknowledgement that you received this Notice of Privacy Practices.


This is a list of some of the types of uses and disclosures of protected health information (PHI) that may occur:


·         Treatment: We obtain health information or PHI about you to treat you.  Your PHI is used by us and others to treat you.  We may also send your PHI to another physician, facility or counselor to which we refer you for treatment, care, procedure, or testing.  We may also use your PHI to contact you to tell you about alternative treatments or other health related benefits we offer.  If you have a friend or family member involved in your care, we may give them PHI about you.


·         Payment: We use your PHI to obtain payment for the services that we render.  For example, we send PHI to Medicare or your insurance plan to obtain payment for our services.


·         Health Care Operations: We use your PHI for our operations.  For example, we may use your PHI in determining whether we are giving adequate treatment to our patients.  On occasion, we may use your PHI to contact you to remind you of an appointment. 


·         Legal Requirements: We may use and disclose your PHI as required or authorized by law. For example, we may use or disclose your PHI for the following reasons:


·         Public Health: We may disclose your health information to prevent or control disease, injury or disability, to report births and deaths, to report reactions to medicines or medical devices or to report suspected cases of abuse or neglect.


·         Health Oversight Activities: We may use and disclose your PHI to state agencies and federal government authorities when required to do so. We may use and disclose your health information in order to assist others in determining your eligibility for public benefit programs and to coordinate delivery of those programs.  For example, we must give PHI to the Secretary of Health and Human Services in an investigation into our compliance with the federal privacy rule.


·         Judicial and Administrative Proceedings: We may use and disclose your PHI in judicial and administrative proceedings.  Efforts may be made to contact you prior to a disclosure of your PHI to the party seeking information. 


·         Law Enforcement: We may use and disclose your PHI in order to comply with requests pursuant to a court order, warrant, subpoena, summons, or similar process.  We may use and disclose PHI to locate someone who is missing, to identify a crime victim, or report a death, to report criminal activity at our offices, or in an emergency.


·         Avert a Serious Threat to Health or Safety: We may use or disclose your PHI to stop you or someone else from getting hurt.


·         Work Related Injuries: We may use or disclose PHI to an employer if the employer is conducting medical workplace surveillance or to evaluate work-related injuries.


·         Coroners, Medical Examiners, and Funeral Directors: We may use or disclose PHI to a coroner or medical examiner in some situations. For example, PHI may be needed to identify a deceased person or determine identity.



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