For forms requiring completion by one of our providers, please note the following:
We charge $20.00 per patient, per form.
Turnaround time for form completion is 24-48 hours.
If the form is needed same day, the charge is $40.00.
Payment is due at the time of the request, and we do not bill for forms.
All forms must be emailed to firstname.lastname@example.org
If you wish to have any forms mailed back to you, please provide a self-addressed, stamped envelope.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Authorization form for MIPA to disclose records to third-parties.
Registration form, financial policy and privacy practices agreements, and past patient/family medical history.
Please complete the family medical history with as much detail as possible -- we can use this information for reference over the course of your child's life. As with all other patient records, it will be kept confidential.
New address or insurance? Fill in your updated info on the registration form (you may leave other sections blank) and bring to your next appointment.
This form is to be completed by patients over the age of 18 that want their parent/guardian to be able to access certain types of healthcare information on their behalf, such as requesting medication refills, picking up rx's, or scheduling appointments.
Authorization form that, in the event of need for routine or emergency medical care, allows a named individual (such as a grandparent or family friend) to provide informed consent for a minor in the absence of their legal guardian.
Named individuals will be required to provide self-identification.
Sports participation, med-at-school, and other forms for local school districts.
Please complete the patient/history portion of forms prior to exam appointment - doctors are unable to complete and sign until you have done so.
Form stating exemption from immunizations for religious, personal, philosophical, and medical reasons.