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 Summary
Form (for new patients) -
PDF, 34 KB
Please complete, date, and sign. Revised version 10/13/11 -
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 2 pages of the HIPAA forms below.
Please complete, date and sign. Revised version 4/26/11 includes permissions to contact you via text messaging and email.
HIPAA - Consent for Use and Disclosure of Health Information and Acknowledgment of Receipt of Privacy Notice - 2-page PDF, 27 KB. Here is where you specify that you allow us to share your personal information when necessary, and indicate how we can contact you and who can receive messages in your behalf.
Should you wish to see our full Notice of Privacy Practices, you may download it here (PDF, 28 KB, opens in a separate window.)
3. All patients, current and new, must sign this document, effective June 1, 2010:
- Office Financial and Insurance Policy - PDF, 17 KB rev. 4/20/10. Please complete, date, and sign this document.
- Español -- Política financiera y de seguros del consultório - PDF, 21 KB, rev. 4/20/10, efectiva en el 1 de junio de 2010
4. 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.