Patient Forms

Patient Forms

The following are some forms you may find useful.

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.

In-House Record Transfer Form

This form is used to ask one of our offices to send your records to another one of our offices.

Patient Forms

Authorization for Release of Medical Information (PDF) - Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility. Autorización De HIPAA Para Divulgar Información Del Paciente

Authorization and Consent for Treatment (PDF) - All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento

Preferred Contacts (PDF) - Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos

Virtual Visit Policy (PDF) - This policy describes the process for the documentation, maintenance, and transmission of information using virtual visit technology.

Office Policies

Financial Policy (PDF) - This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations. Política Financiera (PDF)

Notice of Privacy Practices (PDF) - 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. Aviso de prácticas de privacidad (PDF)

HIPAA Privacy Notice