Patient Forms

Patient Information and Medical History Forms

To make your visit less time consuming, we ask that you fill out and print the Patient Information and Medical History Forms. Please bring the completed forms with you when you come in for your appointment. Filling out these forms will enable us to serve you better and faster.

  1. Patients can print the Patient Information and Medical History Forms and complete them with a black ink pen or you can download and install Adobe Acrobat Reader which will
    enable you to fill out the Patient Information and Medical History Forms or any .PDF form right on your computer before printing them.

  2. Fill out your form!


Effective date: April 14, 2003

We understand that health information about you and your health is personal. We are committed to protecting health information about you. We create a record of the care and services your receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by this office, whether made by your personal doctor or others working in this office. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

We are required by law to:

  • Make sure that health information that identifies you is kept private.

  • Give you this Notice of our legal duties and privacy practices with respect to health information about you.

  • Follow the terms of the Notice that is currently in effect.

How we may use and disclose health information about you:

  • For treatment.

  • For payment.

  • For health care operations.

  • For appointment reminders.

  • As required by law.

  • To avert a serious threat to health and safety.

  • As required by the Military or Veterans and Workers Compensation.

  • Public Health risks.

  • >Health oversight activities.

  • Lawsuits and disputes.

  • Law enforcement.

  • Coroners, health examiners and funeral directors.

  • National Security and Intelligence activities.

  • Protective Services for the President and others.

  • Security Officials for Inmates.

Your rights regarding Health Information about you:

  • Right to inspect and copy.

  • Right to amend.

  • Right to an Accounting of Disclosures.

  • Right to Request Restrictions.

  • Right to Request Confidential Communications.

  • Right to a Paper copy of this Notice (full Notice is available upon request).

Changes to this Notice:

We reserve the right to change this Notice. We will post a copy of the current notice in our facility with the current effective date on the first page.


If you believe that your privacy rights have been violated, you may file a complaint with us. All complaints must be in writing. Please contact the administrator at the location where you were treated to file a complaint.

Acknowledgement of Receipt of this Notice:

We will request that you sign a separate form acknowledging you have received a copy of this notice. This acknowledgement will become a part of you records.

We may use and disclose your information to conduct or arrange for services including:

  • Medical quality review by your health plan.

  • Accounting, legal, risk management, and insurance services.

  • Audit functions, including fraud and abuse detection and compliance programs.

Your Health Information Rights:

The health and billing records we create and store are the property of the practice/health care facility. The protected health information in it, however, generally belongs to you. You have the right to:

  • Receive, read, and ask questions about this Notice.

  • Ask us to restrict certain uses and disclosures. You must deliver this request in writing to us. We are not required to grant the request, but we will comply with any request granted

  • Request and receive from us a paper copy of this or the most current Notice o Privacy Practices for protected Health Information (“Notice”).

  • Request that you be allowed to see and get a copy of your protected health information. You may make this request in writing. We have a form available for this type of request

  • Have us review a denial of access to your health information—except in certain circumstances.

  • Ask us to change your health information. You may give us this request in writing. You may write a statement of disagreement if your request is denied. It will be stored in your medical record, and included with any release of your records.

  • When you request, we will give you a list of disclosures of your health information. The list will not include disclosures to third-party payors. You may receive this information without charge once every 12 months. We will notify you of the cost involved if you request this information more than once in 12 months.

  • Ask that your health information be given to you by another means or at another location. Please sign, date and give us your request in writing.

  • Cancel prior authorizations to use or disclose health information by giving us a written revocation. Your revocation does not affect information that has already been released. It also does not affect any action taken before we have it. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.

For help with these rights during normal business hours, please contact the administrator of the location at which you have been treated. Please call the main office phone number and ask for the administrator.

Our Responsibilities

We are required to:

  • Keep your protected health information private.

  • Give you this Notice.

  • Follow the terms of this notice.

We have the right to change our practices regarding the protected health information we maintain. If we make changes, we will update this Notice. You may receive the most recent copy of this Notice by calling and asking for it or by visiting our office to pick on up.

To Ask for Help or Complain

If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact the administrator of the location at which you have been treated. Pleas call the main office phone number and ask for the administrator.

If you believe your privacy rights have been violated, you may discuss your concerns with any staff member. You may also deliver a written complaint to the administrator at you practice/health care facility. You may also file a complaint with the U.S. Secretary of Health and Human Services.

We respect your right to file a complaint with us or with the U.S. Secretary of Health and Human Services. If you complain, we will not retaliate against you.


Other Disclosures and Uses of Protected Health Information

Notification of Family and Others

Unless you object, we may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may tell your family or friends your condition and that you are in a hospital. In addition, we may disclose health information about you to assist in disaster relief efforts.

You have the right to object to this use or disclosure of you information. If you object, we will not use or disclose it.

We may use and disclose your protected health information without your authorization as follows:

  • With Medical Researchers—if the research has been approved and has policies to protect the privacy of your health information. We may also share information with medical researches preparing to conduct a research project.

  • To Funeral Directors/Coroners consistent with applicable law to allow them to carry out their duties.

  • To Organ Procurement Organizations (tissue donation and transplant) or persons who obtain, store, or transplant organs.

  • To the Food and Drug Administration (FDA) relating to problems with food, supplements, and products.

  • To Comply with Workers’ Compensation Laws—If you make a workers’ compensation claim.

  • For Public Health and Safety Purposes as Allowed or Required by Law:

    • to prevent or reduce a serious, immediate threat to the health or safety of a person.

    • or the public.

    • to public health or legal authorities.

      • to protect public health and safety.

      • to prevent or control disease, injury, or disability.

      • to report vital statistics such as births or deaths.

  • To Report Suspected Abuse or Neglect to public authorities

  • To Correctional Institutions if you are in jail or prison, as necessary for your health and the health and safety of others.

  • For Law Enforcement Purposes such as when we receive a subpoena, court order, or other legal process, or you are the victim of a crime.

  • For Health and Safety Oversight Activities. For example, we may share health information with the Department of Health.

  • For Disaster Relief Purposes. For example, we may share health information with disaster relief agencies to assist in notification of your condition to family or others.

  • For Work-Related Conditions That Could Affect Employee Health. For example, and employer may ask us to assess health risks on a job site.

  • To the Military Authorities of U.S. and Foreign Military Personnel. For example, the law may require us to provide information necessary to a military mission.

  • In the Course of Judicial/Administrative Proceedings at your request, or as directed by a subpoena or court order.

  • For Specialized Government Functions. For example, we may share information for national security purposes.

Other Uses and Disclosures of Protected Health Information

  • Uses and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization.

Effective Date:

April 14, 2003

Patient Forms