Forms for Patients
We too wish there wasn't so much paperwork. Unfortunately we are obliged to subject you to this.
To save yourself 20 minutes at our office, you may download and print these forms, and fill them out before you come.
REMEMBER TO BRING THE COMPLETED FORMS WITH YOU!
Consider:
- placing the forms in an envelope or folder
- keeping them in your car or bag which you'll bring to your appointment, or
- finding a different way to remind yourself to bring them in.
(Penalty for forgetting to bring the forms: you'll need to fill them out all over again at the office.)
To access these forms you will need Adobe Acrobat Reader (TM) (free download).
YOU MAY BE ABLE TO DOWNLOAD THE FORMS TO YOUR COMPUTER, rather than open them in your browser, by right-clicking each link and choosing "save."
1. Please choose, between the two forms below, the one that applies to you.
-
Patient Medical History
Form (for new patients) -
PDF, 196 KB
Please complete, date, and sign -
Patient Medical History
Update Form (for existing patients
who have not updated their medical history with us in the past 12
months) - PDF, 22 KB, revised 6/16/09.
Please complete, date, and sign - Español -- Cambios en el historial medico - PDF, 123 KB, rev. 6/22/09
2. All patients, current and new, must address the three HIPAA forms below.
-
HIPAA - Privacy Policy for this Office - PDF, 36 KB,
revised 2/1/08
Please read and review. Based on the content of our HIPAA policy, you can choose or not to sign [b] below.
At the office you will usually be given a two-sided printout (PDF, 39 KB, revised 4/12/08) containing HIPAA Form 1 and HIPAA Form 2 described below. You may print and fill out this form instead of [b] and [c] below.
- HIPAA -
Consent for Use and Disclosure of Health Information
- PDF, 23 KB - "HIPAA Form 1," revised 4/12/08
If you consent to this office's HIPAA Privacy Policy [a], please fill out and sign page 1 of [b]. If you're giving consent, you must leave page 2 of [b] blank. -
HIPAA - Acknowledgement Receipt of Privacy
Notice - PDF, 29 KB - "HIPAA Form 2," revised
5/21/08
Whether or not you read [a] or signed [b], we need you to sign this form [c] declaring that you were given the opportunity to examine this office's HIPAA Policy, and specifying who this office can communicate with.
5. All patients, current and new, must sign this document:
-
Office Financial and Insurance Policy - PDF, 16 KB
rev. 12/8/07
Please complete, date, and sign this document. - Español -- Política financiera y de seguros del consultório - PDF, 21 KB, rev. 12/15/08
6. If you have dental insurance, please address the new Dental Claim Form - PDF, 491 KB
- If you are a new patient who has dental insurance. please complete the highlighted sections of this form, date, and sign it.
- If you are a current patient, please examine the highlighted areas of this form. If there have been any changes to your situation, please fill out the form.
If you've filled out these forms, you must bring them to the office and deliver them to the Front Desk BEFORE you can see our clinicians.