Patient Forms

Patient Forms

New Patient Request Form

Patients wishing to establish with one of our providers should complete this form and follow the return instructions included in the form.

Health Risk Assessment

Patients who are coming for a Medicare Wellness Exam should complete this form and bring it with them to their appointment.

Diagnostic Center Ultrasound Preparations

Patients who are coming for an ultrasound should review this form in advance, as certain exams require specific preparations.

Administrative Forms

Authorization for Release of Medical Information

Autorización De HIPAA Para Divulgar Información Del Paciente

Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.

Authorization and Consent for Treatment

Autorización y Consentimiento Para el Tratamiento

All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.

Preferred Contacts

Contactos Preferidos

Patients are encouraged to complete and return the Preferred Contacts Form but it is not required.

Virtual Visit Policy

This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

Office Policies

Financial Policy

Política Financiera (PDF)

This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.

Notice of Privacy Practices

Aviso de prácticas de privacidad

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.

HIPAA Privacy Notice

Language Services