Patient Insurance Information Please complete this form prior to arrival so that we can have the most up to date information on you as well as your insurance coverage. If you do not have insurance, please complete the top section only.

Medical History and Review of Systems In order to provide for your health needs concerning your medical care, we would like you to answer the following questions. This information will become a part of your confidential medical record. If you do not understand our questions place a “?” alongside. PLEASE PRINT. Thank you.

About Financial Arrangements and Medical Insurance We are committed to providing you with quality care in a concerned professional environment. If you have medical insurance, we are determined to help you receive your maximum allowable benefits. Our main focus is "your health and what is best for you," rather than what benefits the insurance company. In order to achieve these goals, we need your assistance and your understanding of our payment policy. Payment for services is due at the time services are rendered. By printing and signing this form you will shorten the time required for your first visit.

Authorization for Access To and Release of Medical Information In order for us to request and receive medical records from your previous physician, we will need for you to complete this form for this to even happen.

Annual Update or Frequently Requested Forms

About Financial Arrangements and Medical Insurance We are committed to providing you with quality care in a concerned professional environment. If you have medical insurance, we are determined to help you receive your maximum allowable benefits. Our main focus is "your health and what is best for you," rather than what benefits the insurance company. In order to achieve these goals, we need your assistance and your understanding of our payment policy. Payment for services is due at the time services are rendered. By printing and signing this form you will shorten the time required for your first visit.

Authorization for Access To and Release of Medical Information In order for us to request and receive medical records from your previous physician, we will need for you to complete this form for this to even happen.

HIPAA Forms

Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read it carefully. Anyone has a right to ask for a paper copy of this notice at any time.

Notice of Privacy Practices and Acknowledgement Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations.